A 34-year-old woman comes to the physician with complaints of periodic visual obscurations. She has episodes during which she goes blind for several seconds when standing up or stooping forward abruptly. She also describes frequent morning headaches over the last 2 months for which she takes ibuprofen or aspirin almost every morning. The patient takes no other medications. Her past medical history is insignificant except for an uncomplicated vaginal delivery. She does not use tobacco, alcohol, or illicit drugs. Her temperature is 36.4 C (97.6 F), blood pressure is 138/88 mm Hg, and pulse is 93/min. Her body mass index is 35 kg/m². Visual field testing shows enlarged blind spots. Which of the following ocular features is most commonly associated with this patient's condition?

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This patient's presentation suggests papilledema due to increased intracranial pressure (ICP). The elevated ICP is transmitted to the optic nerve sheath, resulting in swelling of the optic nerve head. This can be visualized as papilledema on ophthalmologic examination. Normal individuals have a blind spot in their visual fields at the location of the optic nerve head; this blind spot enlarges in those with papilledema. Papilledema can cause momentary vision loss that varies according to changes in head positioning. It can also lead rapidly to permanent vision loss and requires urgent diagnostic evaluation. papilledema Although headaches can be due to a variety of etiologies, those secondary to increased ICP are often worse in the morning, as in this patient. There is no definite cause of the patient's elevated ICP in this question. However, given her fairly young age, obesity, and lack of additional comorbidities, one likely cause is idiopathic intracranial hypertension (also known as pseudotumor cerebri). The next step is to obtain neuroimaging (computed tomography or magnetic resonance imaging of the brain) to exclude an underlying mass lesion or other central nervous system abnormality. (Choice A) Amaurosis fugax is painless, transient monocular blindness that lasts a few seconds. It is usually vascular (eg, embolus to ophthalmic artery) in origin. Amaurosis fugax would be unlikely in this patient given her young age and low risk of atherosclerosis. (Choice B) Cataracts typically present with gradual loss of vision as opposed to the intermittent symptoms experienced by this patient. (Choice C) Glaucoma is caused by increased intraocular pressure. Patients may have peripheral visual field deficits, but they would not complain of intermittent vision loss with changes in head position. Glaucoma (Choice D) Optic neuritis is commonly associated with multiple sclerosis but can be seen with other disorders as well. It typically presents as unilateral eye pain and vision loss with an associated afferent pupillary defect. Optic neuritis (Choice F) Anterior uveitis presents with eye pain and redness, whereas posterior uveitis is often painless and associated with floaters or reduced visual acuity. In contrast, patients with papilledema do not have eye redness or persistent deficits of visual acuity until late in the course of the disease. Anterior uveitis Educational objective: Papilledema is caused by increased intracranial pressure and presents with transient vision loss lasting a few seconds with changes in head position. It requires urgent diagnostic evaluation (eg, ophthalmologic examination, neuroimaging, and/or lumbar puncture) as persistent papilledema can lead to vision loss. References: Association between visual parameters and neuroimaging features of idiopathic intracranial hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/23850064) Unilateral papilledema in pseudotumor cerebri. (http://www.ncbi.nlm.nih.gov/pubmed/23627435)

A 34-Year-Old Woman Comes to the Physician with Complaints of Periodic