Figure 1A. The patient’s right eye fundus photo shows optic nerve swelling consistent with Frisen grade 4.
Figure 1B. As in the right eye, this image of the patient’s left eye shows complete obscuration of the disc margin and vessels, and chorioretinal folds. This eye’s fundus image also shows a splinter hemorrhage inferiorly off the disc, and a hemorrhage superiorly in the disc head.
Figure 2A. The left eye’s visual field test shows marked enlargement of a blind spot and nasal defect.
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Figure 2B. Like the left, this visual field test of the patient’s right eye shows an enlarged blind spot and nasal defect. Evidence of arcuate defects coming from the blind spot were also seen, but in this eye only.
Figure 3A. A brain MRI shows a large extra axial enhancing mass abutting the right greater wing of the sphenoid and overlying the frontal and temporal lobes.
Figure 3B. A second view of the brain MRI showing a large extra axial enhancing mass abutting the right greater wing of the sphenoid.
A 32-year-old woman presented to the clinic with progressively worsening frontal headaches that she reported experiencing for 2 months. She was 3 months postpartum and described experiencing a “pulsing sound” in her ears as well as episodic visual loss associated with changes in light intensity and positional movement.
Upon examination her vision was 20/20-1 OU (Snellen), intraocular pressures were 18 mm Hg OD and 19 mm Hg OS, and her pupils appeared normal with no afferent pupillary defect. Her color vision and extraocular movements were normal. Vital signs were within normal limits. On slit lamp examination, the anterior segments appeared normal in both eyes. A fundus examination revealed optic nerve swelling consistent with Frisen grade 4, complete obscuration of the disc margin and vessels, and chorioretinal folds in both eyes (Figures 1A and 1B). The left fundus was also notable for a splinter hemorrhage inferiorly off the disc, and a hemorrhage superiorly in the disc head.
Visual field testing showed marked enlargement of the blind spot and nasal defects in both eyes (Figures 2A and 2B). Evidence of arcuate defects coming from the blind spot were noted in the left eye. An MRI of the brain showed a large extra axial enhancing mass abutting the right greater wing of the sphenoid and overlying the frontal and temporal lobes (Figures 3A and 3B).
Papilledema refers to swelling of the optic disc due to increased intracranial pressure.1 Urgent evaluation is required to ensure timely management of the underlying cause. Conditions that can cause papilledema include, but are not limited to, intracranial tumors, infection, hemorrhage,...
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Papilledema refers to swelling of the optic disc due to increased intracranial pressure.1 Urgent evaluation is required to ensure timely management of the underlying cause. Conditions that can cause papilledema include, but are not limited to, intracranial tumors, infection, hemorrhage, cerebral venous sinus thrombosis, idiopathic intracranial hypertension, and malignant hypertension.1 On the other hand, optic disc edema is swelling of the optic disc due to optic neuropathy of any cause.1 The Frisen scale is commonly used to grade the severity of papilledema on fundus examination.2 Grade 4 edema, as seen in this patient, denotes obscuration of major blood vessels in the optic disc.3
This patient had a large (approximately 6.5 cm) extra-axial mass consistent with meningioma on brain imaging. Meningiomas are the most common primary tumor of the central nervous system and affect women more than men.4 Meningiomas can also grow during pregnancy. Possible mechanisms include endocrine or vascular factors.5
This patient had an urgent neurosurgical consult and underwent a craniotomy 3 days later. Postoperatively, her vision was 20/20-2 OD and 20/15-1 OS, and fundus examination showed disc pallor in both eyes. There were no further episodes of transient vision loss.
This case was contributed by Kanza Aziz, MD, a research fellow at the Department of Ophthalmology, Massachusetts Eye and Ear at Harvard Medical School, Boston.
The case was edited by Grayson W. Armstrong, MD, MPH, an instructor of ophthalmology at Massachusetts Eye and Ear and Harvard Medical School and Director of Ophthalmology Emergency Service.
- Xie JS, Donaldson L, Margolin E. Papilledema: a review of etiology, pathophysiology, diagnosis, and management. Surv Ophthalmol. 2022;67(4):1135-1159. doi:10.1016/j.survophthal.2021.11.007
- Frisén L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry. 1982;45(1):13-18. doi:10.1136/jnnp.45.1.13
- Frisen Grandes. The American Academy of Ophthalmology. Accessed June 29, 2023. https://www.aao.org/education/image/frisen-grades
- Buerki RA, Horbinski CM, Kruser T, Horowitz PM, James CD, Lukas RV. An overview of meningiomas. Future Oncol. 2018;14(21):2161-2177. doi:10.2217/fon-2018-0006
- Hortobágyi T, Bencze J, Murnyák B, Kouhsari MC, Bognár L, Marko-Varga G. Pathophysiology of meningioma growth in pregnancy. Open Med (Wars). 2017;12:195-200. doi:10.1515/med-2017-0029