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A man with blurred vision and headache
  1. Yen-Chiang Lee,
  2. Yu-Chang Liu,
  3. Wei-Jing Lee
  1. Emergency Medicine, Chi Mei Foundation Hospital, Tainan, Taiwan
  1. Correspondence to Dr Wei-Jing Lee, Emergency Medicine, Chi Mei Foundation Hospital, Tainan, Taiwan; saab931103{at}yahoo.com.tw

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Clinical Introduction

A 51-year-old man with a medical history of hypertension presented to the ED with a 2-week headache and blurred vision, in addition to a visual defect for over 1 month. Under ophthalmic examination, visual acuity was 0.8/0.4 (1.0) and visual field test showed right 3/4 quadrantanopsia. Ocular point-of-care ultrasound was performed (figure 1).

Figure 1

Point-of-care ultrasound of the right eye.

Question

What is the most likely diagnosis?

  1. Retrobulbar mass

  2. Retinal detachment

  3. Papilloedema with increased intracranial pressure

  4. Vitreous haemorrhage

Answer

C. Papilloedema with increased intracranial pressure.

Ultrasonographic optic nerve sheath diameter (ONSD) and optic disc height measurement can serve as a rapid, non-invasive method for bedside assessment of intracranial pressure (ICP). Optic disc protrusion and disc height greater than 0.6 mm are strongly associated with papilloedema.1 An estimated ONSD greater than 5 mm is consistent with ICP >20 cm H2O.2 In this case, ocular ultrasound showed protrusion of the optic disc and an enlarged ONSD of 6.25 mm (figure 2 and online supplemental video 1).

Figure 2

Point-of-care ultrasound of the right eye revealed protrusion of the optic disc into the vitreous cavity (arrowhead) and an enlarged optic nerve sheath diameter of 6.25 mm (bold arrow).

Papilloedema is defined as optic disc swelling secondary to increased ICP. Common causes of papilloedema include space-occupying lesions of the brain such as tumour, intracranial haemorrhage, central nervous system infections, idiopathic intracranial hypertension or uncontrolled hypertension.3 Papilloedema can result in vision loss and optic nerve injury if not diagnosed and treated early.

CT of the brain confirmed the diagnosis of papilloedema, with increased ICP caused by parieto-occipital parasagittal tumour (7.7×6.8×6.3 cm) (figure 3). The patient was initially treated with intravenous steroid, and craniotomy was subsequently performed a few days later to remove the brain tumour.

Figure 3

CT of the brain revealed parieto-occipital parasagittal tumour (7.7×6.8×6.3 cm) with invasion into the superior sagittal sinus and surrounding skull bone, causing mass effect with peritumoral oedema and mild midline shift (bold arrow).

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References

Footnotes

  • Contributors The authors have provided equal contribution to this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.