Papilloedema and optic nerve disorders: Case

Framing the case

This twelve-year-old girl has the classic presentation of the idiopathic intracranial hypertension with the morning headache, the transient visual obscurations, the diplopia and the bilateral disc swelling. The framework that organises the case is the urgent neuroimaging, the Friedman criteria and the vision surveillance, and the first priority is the magnetic resonance imaging with the venography before the lumbar puncture, because the bilateral disc swelling is the raised intracranial pressure until proven otherwise. ^[1][2]

Confirming the diagnosis

The magnetic resonance imaging with the venography is performed urgently to exclude the tumour, the hydrocephalus and the venous sinus thrombosis. The lumbar puncture follows the normal neuroimaging, in the lateral decubitus position with the child relaxed and the legs extended, and the opening pressure is measured with the manometer before the fluid is removed. The opening pressure above two hundred and eighty millimetres of cerebrospinal fluid in the child confirms the raised pressure, and the normal composition excludes the meningitis and the inflammation. The Friedman criteria are fulfilled, and the idiopathic intracranial hypertension is the diagnosis after the secondary cause is excluded. ^[1][3]

Grading the papilloedema

The Frisén grading scale is applied to the disc swelling, and it drives the urgency and the surveillance. The grade one is the C-shaped halo that spares the temporal margin, the grade two is the complete halo, the grade three is the elevation with the halo and the early vessel deflection, the grade four is the partial obscuration of the major vessels, and the grade five is the complete obscuration of all the vessels. The visual acuity, the colour vision and the visual fields are assessed, with the optical coherence tomography of the retinal nerve fibre layer, and the enlarged blind spot and the field constriction are the early defects. ^[1][6]