An 11-year-old girl is brought to the clinic due to blurry vision. The symptoms began 2 weeks ago at school, when a teacher noticed that the child often moved closer to the front of the classroom to see the board. At home, the patient takes frequent breaks when playing video games because of nausea and headaches. She has type 1 diabetes mellitus, which was diagnosed 2 years ago after she was hospitalized for diabetic ketoacidosis. Since then, the diabetes has been well controlled with insulin. The patient's vision examination 6 months ago was normal. Visual acuity today shows 20/40 bilaterally with no changes after refraction. The pupils are equal and reactive to light, and extraocular movements are intact. Visual fields are full, with enlarged blind spots bilaterally. Dilated retinal examination is shown in the image below: The remainder of the neurologic examination is normal. Which of the following is the most likely cause of this patient's symptoms?

Question

An 11-year-old girl is brought to the clinic due to blurry vision.  The symptoms began 2 weeks ago at school, when a teacher noticed that the child often moved closer to the front of the classroom to see the board.  At home, the patient takes frequent breaks when playing video games because of nausea and headaches.  She has type 1 diabetes mellitus, which was diagnosed 2 years ago after she was hospitalized for diabetic ketoacidosis.  Since then, the diabetes has been well controlled with insulin.  The patient's vision examination 6 months ago was normal.  Visual acuity today shows 20/40 bilaterally with no changes after refraction.  The pupils are equal and reactive to light, and extraocular movements are intact.  Visual fields are full, with enlarged blind spots bilaterally.  Dilated retinal examination is shown in the image below:  The remainder of the neurologic examination is normal.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d6f3_2aaa_bc81_d9aa90c92e86_MD0003_00 This patient has vision changes and optic disc swelling, most likely due to idiopathic intracranial hypertension (IIH). Although IIH most commonly occurs in obese women of childbearing age, the condition can also be seen in nonobese children. In the prepubertal population, headache may be less obvious and vision abnormalities may be the predominant finding. Increased intracranial pressure (ICP) on the optic disc causes swelling (papilledema), leading to blurry vision that does not improve with refraction and an enlarged blind spot. On funduscopic examination, the optic disc appears elevated with blurred margins, and vessels may be engorged or leaky (ie, splinter hemorrhages). In young children, increased ICP is more likely to affect the cranial nerves, particularly the abducens nerve (CN VI) because of its long course through the skull to the lateral rectus muscle. Patients with CN VI palsy may have diplopia and impaired eye abduction on examination. optic disc The first step in evaluation is neuroimaging to rule out anatomic causes of increased ICP. If neuroimaging is negative, an elevated opening pressure on lumbar puncture is diagnostic of IIH. Treatment involves relieving ICP (eg, acetazolamide) to prevent permanent vision loss. (Choice A) Diabetic retinopathy develops over time in patients with poorly controlled diabetes. Blurry vision can occur due to macular edema, and retinal examination may show neovascularization or exudates but a normal optic disc. Diabetic retinopathy is less likely in this patient with well-controlled diabetes and a normal vision test 6 months ago. Diabetic retinopathy (Choice C) Pituitary adenoma may present with headache and visual abnormalities but classically causes bitemporal hemianopia due to pressure on the optic chiasm. bitemporal hemianopia (Choice D) Retinitis pigmentosa is an inherited disorder characterized by progressive retinal degeneration. The presentation can include night blindness, decreased visual acuity, and visual field loss. Retinal vessel attenuation and optic disc pallor are characteristic findings not seen on this patient's ocular examination. (Choice E) Retinoblastoma is an intraocular tumor that typically presents with a white pupillary reflex in infants and toddlers. Funduscopic examination would show a nodular, cream-colored retinal mass. Educational objective: Although idiopathic intracranial hypertension typically presents in obese women of childbearing age, it can also be seen in children who are not obese. Headaches may be less obvious, and vision abnormalities (eg, blurry vision, enlarged blind spot) are often predominant in the prepubertal population. Papilledema is the hallmark examination finding. References: Pediatric pseudotumor cerebri syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/28806347)

An 11-Year-Old Girl Is Brought to the Clinic Due to Blurry