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| PHOTO ESSAY |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 594-596 |
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Unilateral disk changes in idiopathic intracranial hypertension: Asymmetric papilledema
Shagun Korla, Ravinder Kumar Gupta, Pallavi Kumari
Department of Ophthalmology, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan, Himachal Pradesh, India
| Date of Submission | 11-Nov-2022 |
| Date of Acceptance | 23-Feb-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Shagun Korla
Department of Ophthalmology, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan-173 229, Himachal Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJO.IJO_2988_22
Keywords: Asymmetric papilledema, female, idiopathic intracranial hypertension
How to cite this article:
Korla S, Gupta RK, Kumari P. Unilateral disk changes in idiopathic intracranial hypertension: Asymmetric papilledema. Indian J Ophthalmol Case Rep 2023;3:594-6 |
How to cite this URL:
Korla S, Gupta RK, Kumari P. Unilateral disk changes in idiopathic intracranial hypertension: Asymmetric papilledema. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:594-6. Available from: https://www.ijoreports.in/text.asp?2023/3/2/594/375010 |
Asymmetric papilledema is rare in idiopathic intracranial hypertension (IIH) ,occurring in less than 4% of patients with definite IIH. Asymmetric papilledema is defined as a ≥2 modified Frisén grade difference between the two eyes.[1] Although several mechanisms have been suggested to explain very asymmetric papilledema, such as optic nerve sheath defects and loss of lamina cribrosa compliance, its mechanism remains unclear.[2],[3] Lepore suggested a possible loss of compliance in the aging lamina cribrosa, buffering the effect of the perioptic CSF pressure. Bidot et al. demonstrated that bony optic canal was smaller on the side of the lowest-grade edema. This anatomic configuration allows CSF pressure to be less easily transmitted along the optic nerve on the side of the smaller canal, thereby resulting in lower local intraorbital CSF pressure and thus leading to less optic disc edema.
A 55-year-old female presented with the blurring of vision in her left eye for 3 months which was insidious, painless, and non-progressive. There was no other systemic complaint. On examination, her best corrected visual acuity was 6/6 and 6/24 in right and left eye, respectively. There was no relative afferent pupillary defect. Color vision by Ishihara chart was normal. Anterior segment examination was normal in both eyes. Dilated fundus examination showed a normal posterior segment in the right eye and disk edema in the left eye [Figure 1]. Due to non-availability of a fundus camera, these images were taken by phone camera using 20 D. B scan of the left eye was done to rule out the presence of drusen. OCT of RNFL showed edema of RNFL in the left eye and normal thickness in the right eye [Figure 2]. Routine blood investigations and blood pressure were within normal limits. Contrast Enhanced Magnetic Resonance Imaging of brain showed widening of sella with cerebrospinal fluid signal within and flattening of pituitary suggestive of empty sella [Black arrow, [Figure 3]]. There was dilated subarachnoid space surrounding both the optic nerves [Blue arrow, [Figure 4]]. Optic nerve sheath diameter measured 6 mm and 8 mm on right and left side respectively with flattening of posterior sclera bilaterally [Red arrow, [Figure 4]] features suggestive of papilledema. On Magnetic resonance venography imaging, there was narrowing of left transverse sinus in the lateral aspect, measuring 3 mm with no evidence of venous sinus thrombosis. Diagnosis of asymmetric papilledema was made and medicine consultation was taken for lumbar puncture. She was given intravenous mannitol for 3 days followed by tab acetazolamide. | Figure 1: Fundus photograph of the left eye showing disk edema with 20 D lens (black arrow)
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 | Figure 2: OCT RNFL of the right and left eye showing edema in the left eye and normal RNFL thickness in the right eye
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 | Figure 3: T2-Weighted MRI brain image showing widening of sella with empty sella. (black arrow)
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 | Figure 4: T2-Weighted MRI brain image showing flattening of the posterior sclera (red arrow) with a widening of subarachnoid space around the optic nerve bilaterally (blue arrow)
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| Discussion | |  |
In our case due to aging, a decrease in compliance of lamina cribrosa may be the reason for asymmetric papilledema, although computerized tomography of the bony canal is required to confirm it.
Declaration of consent
The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bidot S, Bruce BB, Saindane AM, Newman NJ, Biousse V. Asymmetric papilledema in idiopathic intracranial hypertension. J Neuroophthalmol 2015;35:31–6.  |
| 2. | Lepore FE. Unilateral and highly asymmetric papilledema in pseudotumor cerebri. Neurology 1992;42:676–8. |
| 3. | Strominger MB, Weiss GB, Mehler MF. Asymptomatic unilateral papilledema in pseudotumor cerebri. J Clin Neuroophthalmol 1992;12:238–41. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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