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A 24-year-old woman with rapidly progressing vision loss
Digital Journal of Ophthalmology 2017
Volume 23, Number 1
January 15, 2017
DOI: 10.5693/djo.03.2016.10.001
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Milad Modabber, MD, MSc | Department of Ophthalmology, McGill University, Montreal, Quebec, Canada
Vasudha Gupta MD, FRCSC | Department of Ophthalmology, Queen’s University, Kingston, Ontario, Canada
Amadeo R. Rodriguez, MD | Department of Surgery Ophthalmology and Medicine Neurology, McMaster University, Hamilton, Ontario, Canada
At initial presentation to the emergency room, the patient’s severity of vision loss prompted her being admitted and started on intravenous methylprednisolone 1 g daily for 3 days as well as oral acetazolamide 250 mg 4 times daily for 2 days. She was unable to tolerate a higher dose of acetazolamide. By the time of neuro-ophthalmological consultation, her visual symptoms had not improved, and she had new-onset abducens nerve palsy of the left eye with diplopia on left lateral gaze.

Given the rapidly progressive visual loss despite maximal tolerated medical treatment, a lumboperitoneal shunt surgery was urgently performed. Opening pressure at the time of the procedure was not recorded. All medications were subsequently discontinued.

One week after surgery, the patient’s vision, diplopia, and headaches had improved. On examination, she had a best-corrected visual acuity of 20/25 in the right eye and 20/30 in the left eye. Pupils were equal and reactive. Ocular motility examination showed resolution of her abducens nerve palsy. Funduscopic examination showed improvement of the papilledema (Figure 1B), and visual field assessment exhibited improved visual fields bilaterally, with a mean deviation of −24.4 dB in the right eye and −18.5 dB in the left eye. Postoperative follow-up at 1, 5, 9, 13, and 18 months demonstrated continued resolution of papilledema and retinal venular dilation and tortuosity (Figure 1C) with improvement of visual fields, with a mean deviation of −13.8 dB in the right eye and −8.4 dB in the left eye (Figure 2D). At final follow-up, 18 months postoperatively, visual acuity had stabilized at 20/25 in each eye. There was mild pallor of both optic nerves, suggesting permanent optic nerve damage. Visual field testing showed persistent inferonasal deficits bilaterally. On follow-up examination, there was mild peripapillary hyperpigmentation nasal to the left optic nerve but no evidence of choroidal neovascularization.