Optic Nerve Head Edema in a Healthy Man in His 20s

Abstract

A previously healthy African American man in his 20s presented to the emergency department after referral by an optometrist for "bleeding in the back of the eye." The patient noted that 2 months prior he began experiencing throbbing headaches in the back of his head that were more painful and associated with lightheadedness when laying down. Two weeks prior to presentation, he started noticing black spots in his peripheral vision and progressive blurring of vision in both eyes. The patient denied recent travel, cough, gastrointestinal or genitourinary tract symptoms, ulcers, aching joints, tinnitus, or transient visual obscurations. He reported owning cats.On presentation, the patient's blood pressure was 210/150 mm Hg, and he had a history of acute kidney failure and non-ST-elevation myocardial infarction. On ophthalmic examination, his uncorrected near visual acuity was 20/25 OD and 20/30 OS. Extraocular motility, Ishihara color plates, intraocular pressure, pupils, and results of slitlamp examination were within normal limits. Ophthalmoscopy showed Frisen grade 5 optic nerve head swelling in both eyes with extensive flame hemorrhages and nerve fiber layer infarcts surrounding both nerves and retinal exudates extending from the nerves temporally into both fovea's (Figure 1). The vessels were of normal course and caliber. There were scattered peripheral dot-and-blot hemorrhages. Results of Humphrey visual field testing were reliable and showed bilateral concentric constriction and enlarged blind spots.