Swollen optic nerves

I am trying to cure my cancer of laziness. So here it goes.

This morning a 26- year old woman came in. Her PCP referred her for eye exam due to headache. She has always suffered from headache since age 8, but recent 5 years it has become worse, sometimes lasting the whole day, and sleeping did not make it better. Initially OTC excedrin helped, but now does not work that well. Her vision is blurry sometimes. She used to wear prescription glasses for reading, but hasn’t for a long time, and now wearing those glasses did not seem to help either. This is an obese female, takes birth control pills, and has a history of type 2 diabetes during pregnancy which resolved since giving birth.

I see a lot of referrals for headache. Almost always the eyes are completely normal. Sure this patient fits the classic “fat fertile female” for idiopathic intracranial hypertension (IIH), but I have seen too many demographics like this that have optic nerves as flat as a shirt. So no expectations here.

However, her optic nerves look slightly elevated. And OCT confirmed thickened retinal nerve fiber layer in some quadrants.

So I guess finally another classical case. I say another because to be fair, this does happen from time to time among the numerous headache patients.


Papilledema due to IIH is often first discovered by eye doctors, because of swollen optic nerves. Patients will then need to go through brain MRI to look for possible mass lesions or blockage of the venous drainage. If none of these, lumbar puncture is done to check for opening pressure of the cerebrospinal fluid (CSF) and look for signs of infection or inflammation in the CSF. If pressure is high but CSF is clear, then a diagnosis of IIH can be made. Patients may be prescribed diamox, which is a carbonic anhydrase inhibitor that reduces CSF pressure; and encouraged to lose weight because for unknown reason, IIH strongly associates with being over-weight. Papilledema usually does not affect vision, but chronic cases may lead to visual field loss and even reduced visual acuity. So we are always on the lookout for optic nerve edema in a patient with headache.

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