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Diagnostic Uncertainty Due to Optic Disc Drusen

Vaphiades, Michael S. DO

Section Editor(s): McCulley, Timothy J. MD

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Journal of Neuro-Ophthalmology: June 2012 - Volume 32 - Issue 2 - p 145-147
doi: 10.1097/WNO.0b013e3182452f6a
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An 80-year-old woman complained of headaches, but she denied other symptoms of giant cell arteritis. She had a history of chronic anxiety for which she was taking sertraline. Visual acuity was 20/25 bilaterally, and color vision and pupillary reactions were normal. Eye movements were full, and funduscopy revealed that both optic discs contained drusen and were edematous with peripapillary hemorrhages (Fig. 1A). Automated visual fields demonstrated peripheral nerve fiber bundle defects in each eye (Fig. 1B). B-scan ultrasound showed prominent optic nerve drusen bilaterally (Fig. 1C). Fluorescein angiography showed the presence of optic disc drusen and dye leakage in the late phases of the angiogram, more of the right disc than of the left disc.

FIG. 1
FIG. 1:
A. Bilateral optic disc edema with optic disc drusen and peripapillary hemorrhages. B. Automated visual fields demonstrating peripheral nerve fiber bundle defects in each eye. C. Ocular ultrasonography showing prominent optic disc drusen bilaterally.

With good visual acuity and intact color vision, increased intracranial pressure was suspected. MRI of the brain showed only white matter ischemic changes consistent with the patient's age. Complete blood count, metabolic panel including blood glucose, and Westergren sedimentation rate were normal. Lumbar puncture showed an opening pressure of 17 cm H20 with normal cerebrospinal fluid analysis. The patient was prescribed gabapentin with relief of her headaches. Examination 7 months later showed resolved optic disc edema and peripapillary hemorrhage OD and nearly resolved peripapillary hemorrhage OS (Fig. 2).

FIG. 2
FIG. 2:
Seven months later, fundus appearance showing less optic disc edema and decrease in the size of the peripapillary hemorrhages.

Optic disc drusen are a frequent cause of optic disc elevation, raising the possibility of optic disc edema. Papillary and peripapillary hemorrhages with or without optic disc edema may occur with optic disc drusen further confounding the clinical picture. Retinal hemorrhages associated with optic disc drusen are rare, and bilateral simultaneous hemorrhages are rarer still (1–3). Hemorrhage associated with optic disc drusen have been described in the following settings: 1) small nerve fiber hemorrhages localized to the optic disc, 2) optic nerve head hemorrhages extending into the vitreous, and 3) subretinal peripapillary hemorrhages with or without associated choroidal neovascularization (2–4).

Optic disc edema associated with optic disc drusen may occur in 1) nonarteritic anterior ischemic optic neuropathy (NAION) (5,6), 2) raised intracranial pressure (7), and 3) association with hemorrhagic events (1). In my patient, the results of the visual field testing were nondiagnostic and were consistent with optic disc drusen, NAION, and chronic papilledema.

The presence of optic disc drusen almost always obviates the need for further patient testing. Such was not the case in my patient since chronic papilledema was a diagnostic consideration and necessitated neurologic evaluation.


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