Woman referred for blurred vision, retro-orbital headache
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A 45-year-old white woman was referred for 3 weeks of blurred vision in the left eye and retro-orbital headache. Best-corrected visual acuities were 20/20 in the right eye and 20/40 in the left eye. Confrontation visual fields were full, and automated perimetry (HVF 30-2 SITA Fast) showed enlarged blind spots bilaterally. Extraocular motility was full. The anterior segment examination was unremarkable. The posterior segment examination was pertinent for bilateral moderate disc edema and hyperemia with mild retinal exudates and Paton’s lines, Physical examination revealed no localized neurologic findings, and her blood pressure was normal. Initial blood work including HbA1c and infectious serologies including Bartonella henselae and Lyme disease were within normal limits. CBC results were consistent with her known microcytic anemia. MRI of the brain and orbits, with and without contrast, did not show any compressive lesions, inflammation of the optic nerves or white matter changes. MRV of the head showed bilateral dural venous sinus thrombosis of the transverse sinuses, partial occlusion and dilation of the right transverse sinus, and complete occlusion of the left transverse venous sinus. The patient was diagnosed with bilateral dural venous sinus thrombosis resulting in elevated intracranial pressure associated with bilateral papilledema, headaches and pulsatile tinnitus.

The patient was admitted to the hospital to initiate IV anticoagulation. She was started on a heparin drip and transitioned to apixaban before her discharge. She was also started on oral acetazolamide to treat the elevated intracranial pressure (ICP) until the clots resolved and the ICP normalized. Blood was drawn for a hypercoagulable workup during the admission, and the results ultimately showed elevated PTT, factor VIII, and anti-cardiolipin IgM. On further questioning, it was revealed that she was already undergoing an autoimmune workup for a new-onset malar rash.

Three months after diagnosis while maintained on acetazolamide and apixaban, her headache and pulsatile tinnitus resolved. The papilledema was resolved in both eyes, and automated perimetry testing no longer showed enlarged blind spots.

Source: https://www.healio.com/news/ophthalmology/20200715/woman-referred-for-blurred-vision-retroorbital-headache
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