Background his case involves a 37-year- old African American female who is diagnosed with idio- T pathic intracranial hyperten- sion (IIH). IIH, previously known as pseudotumor cerebri or benign in- tracranial hypertension, is a condition of increased of unknown etiology.1 Symptoms often include , nausea and pulsat- ing sounds within the head. The most Idiopathic Intracranial significant ocular sign is edema.2 The greatest consequence of Hypertension: the bilateral optic disc edema in IIH is vision loss.3 Up to 25% of IIH patients A Teaching Case Report will develop permanent vision loss.4 Persistent , depression, anxi- ety, reduced quality of life, and loss of Aurora Denial, OD, FAAO vision are often long-term consequenc- es of the condition.5 The economic cost Nancy B. Carlson, OD, FAAO of this condition is significant and esti- mated to exceed $444 million annually in the United States.6 This teaching case report will highlight the overall role of the primary care optometrist in the management of a patient with IIH. The case specifically Abstract deals with the challenges involved in delivering serious or upsetting news, Idiopathic intracranial hypertension (IIH), previously known as pseudotumor the facilitation of communication, cerebri, is a condition of increased intracranial pressure of unknown etiology. both interprofessional and doctor/pa- The most common ocular sign of the disorder is bilateral optic disc edema. Early tient, and the critical thinking skills and appropriate diagnosis and effective management are crucial. This teaching needed for accurate patient manage- case report will highlight the overall role of the primary care optometrist in the ment. It is appropriate for use with stu- diagnosis and management of a patient with IIH. The case specifically deals with dents who have had at minimum some patient care experience and knowledge the challenges involved in delivering bad or upsetting news to patients, the fa- in ocular and neuroanatomy and ocular cilitation of communication, both interprofessional and doctor/patient, and the disease. At most colleges, it would be critical thinking skills needed for accurate patient management. appropriate for third- and fourth-year Key Words: idiopathic intracranial hypertension, pseudotumor cerebri, primary optometry students. Optic disc edema care, optometrist can indicate a potentially life- or sight- threatening condition; therefore, early and appropriate diagnosis along with effective patient management is cru- cial. Student Discussion Guide Dr. Denial is an Associate Professor of Optometry at the New England College of Optometry and a clinical instructor in the Boston area. Case description Dr. Carlson is a Professor of Optometry at the New England College of Optometry and Chair of Patient PC, a 37-year-old African the Department of Primary Care. American female, presented to a com- munity health center eye clinic for a comprehensive eye exam on May 3, 2011. The community health center provides medical, eye, dental, mental health, urgent care and nutritional ser-

Optometric Education 115 Volume 37, Number 3 / Summer 2012 vices to the people in the community. reported no current use of recreational and poor control. The findings for the The patient had received medical care drugs or alcohol. The patient said she comprehensive eye exam are listed in at the clinic during the past 4 years, al- smoked half a pack of cigarettes per Table 1. though this was the first time she was day. The initial impression was bilateral disc examined at the eye clinic. The patient The initial differential diagnosis based edema. , also could not recall the date or provider of on symptoms and case history con- known as malignant hypertension, vs. her last eye exam. Her main complaint sisted of: (primary other causes for the disc edema were was eye fatigue. Her eyes felt “heavy and or secondary), uncorrected refractive considered. Moderate hypertensive tired.” The eye fatigue would occur af- error, specifically hyperopia, binocular/ with other causes for the ter the patient had been working all day accommodative anomalies, or astheno- disc edema was also a possibility. Al- on the computer, and it had started 3-4 pia related to excessive computer use. though there are many possible differ- months ago. In the past, the eye fatigue The patient was also considered at risk ential diagnoses for disc edema, IIH, had resolved on its own. The patient for second- space-occupying lesion or infection did not wear any spectacle correction ary to her history of poor compliance were the most significant at this time. and reported good distance and near vision. The patient felt the eye fatigue was related to excessive computer use and an increase in job responsibilities, which occurred 3-4 months ago. The Table 1 patient, an administrative assistant at a Comprehensive Initial Eye Exam: May 3, 2011 local university, reported spending ap- proximately 6-8 hours per workday on the computer. She said the symptoms OD OS did improve on the weekend with less Distance and near visual 20/20 20/20 computer use, and she did not report acuity, sc any other ocular symptoms. Pupils equal, round and reactive to light (PERRL) Negative afferent pupillary defect (APD) Past ocular history of the patient and her Motility-extra ocular Smooth, accurate, full and extensive family were unremarkable. Her medical muscles history was positive for hypertension Color vision (Ishihara) 11/11 11/11

for the past 14 years, , asthma Cover test Ortho dist and 4 prism diopters at near and depression. The patient reported longstanding (ongoing at least 3-5 Finger counting fields Full Full

years), occasional headaches relieved by Near-point convergence To the nose Motrin. The headaches were not related to her complaint of eye fatigue and oc- Retinoscopy +0.50= -0.25 x 90 +0.25

curred randomly. There had been no Subjective refraction +0.75= -0.25 x 90 20/20 Plano 20/20 recent changes in her headaches. Her primary care physician (PCP) had eval- Capped meibomian glands lower lid Capped meibomian glands lower lid Otherwise all structures unremark- Otherwise all structures unremarkable uated the headache complaint and felt able tension headaches were the most likely TBUT 5 seconds 5 seconds cause. The patient’s current medications were: hydrochlorothiazide 25 mg per Intraocular pressures 15 mmHg 10 mmHg (GAT) @ 6 p.m. day, linsinopril 40 mg per day, atenolol Dilated @7:30 p.m. 1 drop 2.5% phenylephrine (punctal 1 drop 2.5% phenylephrine (punctal 50 mg per day, and Flovent twice daily. Patient gave consent for occlusion) occlusion) The patient was allergic to Augmentin dilation and indicated she 2 drops 1.0 % tropicamide 2 drops 1.0 % tropicamide understood benefits and and morphine. The patient reported potential side effects fair compliance with hypertension Fundus exam with 90D Disc: elevated, blurred margins, 360 Disc: elevated, blurred margins, 360 medications. She admitted to not using and binocular indirect degrees, hyperemic in color degrees, hyperemic in color Blood vessels: A/V crossing chang- Blood vessels: A/V crossing changes all three of the medications prescribed es with engorgement of vessels with engorgement of vessels for hypertension on a consistent basis. Background: multiple flame-shaped Background: multiple flame-shaped hemorrhages hemorrhages The patient’s medical records were ac- Cup/disc estimate: H/V 20/20% Cup/disc estimate: H/V 20/20% cessed by an electronic medical records Macula: clear Macula: clear Periphery: no holes, tears or detach- Periphery: no holes, tears or detach- system and indicated blood pressure ments ments readings of 150/103 mmHg in 2011 Blood pressure with large- Right arm Left arm and 156/103 mmHg in 2010. At her person cuff, patient sitting 180/115 mmHg 160/120 mmHg annual physical exam in 2011, the pa- Fundus photos Figure 1 OD Figure 2 OS tient’s height was recorded as 61 inches and her weight was recorded as 260 lbs. The patient was alert and oriented and

Optometric Education 116 Volume 37, Number 3 / Summer 2012 Additional impressions were meibomi- an gland dysfunction with secondary dry eye, minimal OD, Figure 1 and asymmetric intraocular pressure. Right Eye at Comprehensive Initial Exam: May 3, 2011 The plan was to immediately escort the patient to the urgent care clinic, which was located within the health center. The next day, the patient would report to the emergency room (ER) of a lo- cal hospital, with a follow-up neuro- appointment within 1 week. Both the urgent care clinic and ER physicians were called in advance to prepare them for the patient’s visit. Plans for the diagnoses of meibomian gland dysfunction with dry eye, refrac- tive error and asymmetric intraocular pressure were deferred until the more emergent issues were addressed. Patient education The patient was educated on the retinal findings and elevated blood pressure. The potential plan for the patient was discussed with the patient. The patient preferred to visit the urgent care depart- ment that night for blood pressure con- trol and the ER the next morning for imaging. The patient was also educated on the importance of compliance with the urgent care and ER visits. The patient was told that the disc ede- ma could be the result of the increase Figure 2 in blood pressure or other conditions. Left Eye at Comprehensive Initial Exam: May 3, 2011 The patient was informed that the other conditions ranged from benign conditions to potentially life- or sight- threatening conditions. The patient was told that the emergency depart- ment of the local hospital was the best place to quickly implement the neces- sary testing to accurately diagnose and manage her condition. The patient was informed of the importance of proper and timely diagnostic testing, which necessitated the visit to the ER. The patient indicated understanding by paraphrasing in her own words the in- formation she received. The patient had many questions and was upset by the potentially serious findings revealed during the examina- tion. She did not anticipate her routine comprehensive exam would necessitate a visit to the ER. As much as possible, all of the patient’s questions were an- swered and the patient was reassured. The patient was given the clinician’s cell phone number and was told that

Optometric Education 117 Volume 37, Number 3 / Summer 2012 the eye clinic staff would be available for her. Table 2 lists the findings for the Table 2 urgent care visit. Urgent Care Visit: May 3, 2011, 8 p.m. Phone conversation with patient: Constitution Alert, no acute distress May 4, 2011, 9 a.m. Skin Normal turgor, color, no bruising The patient was called the following Head Atraumatic, normocephalic morning. She reported feeling “okay” Cardiovascular No murmers, no gallops Respiratory Clear to auscultation but was very anxious about her condi- II-XII intact, DTRs normal, sensation intact tion. She indicated she had transporta- Psych Within normal limits tion to the hospital and assured the cli- Blood pressure (sitting position, right 192/136 mmHg nician she would comply. The patient arm, large cuff) was reassured and reminded of the im- Impression Uncontrolled hypertension portance of proper testing and diagno- Bilateral edema sis. The patient was reminded that she Treatment/management Clonidine 0.2 mg po x 1 Extensive patient education on the importance of blood pres- could call the eye clinic or the clinician sure control at any time to ask questions or to get Follow-up in ER in the morning information or help facilitating follow- Neuro-ophth follow-up, PCP 1-2 days up appointments. Table 3 lists the find- ings for the ER visit. Phone conversation with patient: May 5, 2011, 11 a.m. Table 3 Emergency Room Visit: May 4, 2011, 10 a.m. The patient reported being discharged from the hospital earlier in the morn- ing. The patient reported being given Medical history Hypertension, obesity, asthma and depression Physical examination No systemic causes found for increase in medication for her condition and that (CSF) pressure the ER physician spoke to her about the Opening pressure 320 mm of water, closing pressure 150 mm importance of taking the medication to water, clear yellow fluid obtained prevent loss of vision. She was given an CSF sent for analysis of cell count, chemistry and gram staining appointment by the ER staff with the CSF cytology report subsequently found to be normal attending neurologist for the next day. MRI Within normal limits, no space-occupying lesions or obstructions The patient was informed that the eye Impression IIH clinic would schedule an appointment with a neuro-ophthalmologist within Plan Admission to hospital 250 mg qid by mouth 2 weeks for follow-up. The patient re- Follow-up with neurologist after discharge ported “not feeling well.” The patient felt tired and weak and was told by the hospital staff to spend the day resting. Appointment with neurologist: May 6, 2011 sician. Despite experiencing extreme and alerted to her recent health is- side effects and getting the okay from sues. (There was no record of any The neurology appointment was -initi the neurologist to discontinue the med- communication between the ER or ated and scheduled by the ER person- ication, the patient was still taking the urgent care staff and PCP.) nel. The neurologist confirmed the di- medication. The patient reported being • The patient was instructed to call agnosis and treatment plan initiated in told in the ER that taking the medica- the ER. The patient now reported to the the neurologist to discuss the side tion was important because of the po- effects of the medication and pos- neurologist extreme side effects from tential of losing vision. The patient re- the medication. The patient reported sible visual consequences of dis- ported that her appointment with the continuing it. The patient was re- an inability to walk, disorientation and neurologist was very quick and she felt feeling weak. The neurologist told the assured that she was not bothering she did not have adequate time to ask the neurologist and needed to get patient to discontinue the medication the doctor questions. Despite several at- and keep the neuro-ophthalmology ap- her questions answered. The -pa tempts, she was unable to contact her tient declined the eye clinic’s offer pointment, which was scheduled for PCP at the community health center. May 17, 2011. to contact the neurologist. In order to help the patient, eye clinic • The neuro-ophthalmology ap- Phone conversation with patient: personnel took the following steps: May 8, 2011 pointment was scheduled for 14 • The patient’s PCP was contacted days after the patient’s initial visit The patient was extremely distraught. via the electronic medical records to the clinic. Rescheduling it to a She was suffering side effects from the flagging system, informed of the sooner date was attempted but not medication given to her by the ER phy- patient’s desire to speak with him, possible. Optometric Education 118 Volume 37, Number 3 / Summer 2012 • The patient was reminded she could call the eye clinic any time. Table 4 Neuro-Ophthalmology Findings: May 17, 2011 Phone conversation with patient: May 12, 2011 OD OS Distance and near visual 20/20 20/20 The patient reported talking with the acuity, sc neurologist and her PCP. She was told Pupils Pupils equal, round, and reactive to light (PERRL) to discontinue the medication and reas- Negative afferent pupillary defect (APD) sured that her vision was not in imme- Motility, extra-ocular Smooth, accurate, full and extensive diate danger. The patient followed their muscles instructions and had discontinued the Color vision (Ishihara) Normal Normal medication 1 day prior. She reported Cover test Ortho dist/near feeling “a little better.” The patient was Anterior segment exami- Unremarkable Unremarkable instructed to call her PCP or neurolo- nation gist if her condition did not improve, Fundus Discs with good color and blurring of Discs with good color and blurring of the temp margin the temp margin and she was reminded she also could Intraocular pressure with 13 mmHg 13 mmHg contact the eye clinic with any general applanation @10:30a.m. questions. Humphrey visual fields 22% false positive with -2.97 dB -6.33 dB mean deviation with superior 30-2 SITA-Fast mean deviation and multiple nasal and inferior defects Neuro-ophthalmology appointment: points depressed May 17, 2011 Impression IIH given her elevated opening pressure

The patient was evaluated by the neuro- Plan Monitor for progressive loss, RTC 1 month ophthalmologist. The patient reported no changes in previous ocular or health history. The neuro-ophthalmologist re- Table 5 viewed the results of the lumbar punc- Primary Care Physician Follow-Up: June 4, 2011 ture (LP), magnetic resonance imaging The patient has been monitored and followed by her PCP (MRI) and neurology report. The neu- for control of blood pressure and weight reduction rologist report indicated a diagnosis of IIH. The report also indicated that the Constitution Alert, no acute distress patient was prescribed acetazolamide Skin Normal turgor, color, no bruising Head Atraumatic, normocephalic but was unable to tolerate the medi- Cardiovascular No murmers, no gallops cation. She had discontinued it 6 days Respiratory Clear to auscultation prior and felt “much better.” Table 4 Neurology Cranial nerves II-XII intact, DTRs normal, sensation intact reflects the findings from the neuro- Psych Within normal limits ophthalmology visit. Blood pressure (sitting position, large Right arm 145/89 mmHg cuff) Left arm 170/116 mmHg Phone conversation with patient: Impression Hypertension May 18, 2011 Past diagnosis of IIH The patient reported she was “feeling Treatment/management The patient was given instructions on diet, exercise, and importance of maintaining good compliance with medication. better.” She felt comfortable with the Weight reduction was emphasized and the patient was advised neuro-ophthalmologist and felt she was to schedule a consult with the nutrition department. given adequate time to ask questions. The patient assured us she would com- ply with the follow-up appointments Table 6 with the neuro-ophthalmologist and Follow-Up Visit with Neuro-Ophthalmologist: PCP. The patient was reminded she 1 Month Post Original Visit could call the eye clinic with any ques- History 37-year-old female with IIH, alert and oriented, no complaints, no tions. Tables 5 and 6 reflect the find- change in meds since last visit ings from the follow-up appointments. OD OS Educator’s Guide Distance and near visual acuity, sc 20/20 20/20 Pupils Pupils equal, round, and reactive to light (PERRL) The Educator’s Guide includes the nec- Negative afferent pupillary defect (APD) essary information for teaching and Motility-extra ocular muscles Smooth, accurate, full and extensive discussing the case. The key concepts, Fundus Discs with good color and mild Discs with good color and mild chronic papilledema and vessel chronic papilledema and vessel learning objectives and discussion ques- tortuosity tortuosity tions should guide the teaching of the Impression IIH doing well information in this case. Plan Monitor for progressive visual field loss, RTC 3 month Key concepts 1. The role of communication, devel- Optometric Education 119 Volume 37, Number 3 / Summer 2012 oping patient rapport and trust in action of the pharmaceutical 4. Communication and delivery of patient care. agents involved? serious/upsetting news, doctor/pa- 2. Ethical responsibilities of a primary 2. Differential diagnosis tient relationship care health/eyecare provider. a. What is the differential diag- a. What is the professional obli- 3. The pathophysiology of optic disc nosis from the patient’s pre- gation of the provider in dis- edema, including steady state of ce- senting symptoms and medical closing exam findings? What is rebrospinal fluid (CSF). history? informed consent? Discuss the ethical and legal responsibili- 4. The role of basic science in under- b. Describe the retinal findings ties of a provider in disclosing standing disease in patients. and determine the differential examination findings to a pa- 5. Critical thinking in diagnosis. diagnosis from the patient’s tient even if that information retinal signs and medical his- may increase patient stress. 6. The meaning of a diagnosis of ex- tory. clusion. b. What is the SPIKES model for c. Determine and discuss the dif- delivery of bad news? Learning objectives ferential diagnosis for optic c. Use role-playing and the 1. To gain a general understanding of disc edema. SPIKES model to simulate the IIH, including signs, symptoms, d. How is true optic disc edema delivery of bad news in this patient characteristics, diagnos- differentiated from pseudo case. tic testing, treatment options and disc edema? management. d. Identify the interactions where e. What diagnostic testing is patient/doctor trust was estab- 2. To gain a basic understanding of needed? Include specificity of lished and lost. the grading system for hypertensive testing and potential risk to retinopathy and the management patient. e. Discuss the interprofessional of a hypertensive crisis. communication that facilitat- f. Discuss the concept of a diag- ed or hindered the care of this 3. To apply critical thinking skills to nosis of exclusion. patient. the care of a patient. g. After analysis of all informa- 5. Critical thinking concepts 4. To gain skills in the delivery of up- tion/data, what is the best pos- setting or bad news. sible diagnosis? a. What assumptions are made in the case? 5. To understand the role and respon- 3. Patient management and the role sibilities of the primary care op- of the primary care optometrist b. What inferences are made in tometrist in the management of a the determination of the dif- patient with IIH. a. What is the appropriate op- ferential diagnosis? tometric management of this 6. To understand the critical role of patient? c. What are the implications of communication and building trust prematurely inferring that the and rapport between doctor and b. Discuss the general manage- patient has hypertensive retin- patient. ment of hypertensive retinopa- opathy? thy and the specific manage- Discussion questions ment related to this case. d. What are the potential impli- cations involving the manage- 1. Knowledge, concepts, facts and c. Discuss the role of the primary ment of this patient? information required for critical care eye doctor in measuring review of the case blood pressure. Should this be e. What are the implications of withholding information from a. Describe the anatomy of the done routinely in optometrists’ the patient? optic nerve head. offices as a screening test? f. What is the patient’s point of b. Describe the anatomy that al- d. Describe the role of the prima- view? lows for the outflow of CSF. ry care optometrist in coordi- nating the care of this patient. Literature review c. Discuss the general risk/symp- Does an optometrist have an toms for IIH and compare Historically, IIH was referred to as ethical role to oversee the pa- them to the patient’s individ- benign intracranial hypertension or tient’s care? Is it sufficient for ual risk/symptoms factors. pseudotumor cerebri. The term idio- the optometrist to just make pathic implies that the cause is un- d. Describe hypertensive retin- the appropriate referral? known. The condition is defined by an opathy fundus findings and e. What pertinent information increase in intracranial pressure charac- describe the grading criteria. should be used to educate the terized by a rise in CSF pressure with e. What is the pathophysiology patient regarding the condi- normal CSF composition, in the ab- of IIH? tion and who should give this sence of any masses, abnormali- 1 f. What is the mechanism of information to the patient? ties or secondary causes.

Optometric Education 120 Volume 37, Number 3 / Summer 2012 Although the disorder can occur in tic nerve communicates with the suba- by 58% of patients.17 These noises can children and men, it most frequently rachnoid spaces around other parts of vary in description, intensity and dura- occurs in women age 20-50 who are the brain.10 The formation of optic nerve tion.2 The noises have been described overweight.1 Several studies have dem- edema depends on the interaction of by patients as “buzzing,” “thumping” or onstrated that African American pa- CSF pressure, intraocular pressure and “heartbeat.”17 The causes of the noises tients and men with the condition have systemic blood pressure.11 An increase are believed to be related to the move- a more aggressive form of the disease in CSF pressure from overproduction, ment of CSF under high pressure.20 and require more aggressive interven- underabsorption or any obstruction of • Papilledema tion.7 The incidence of this condition CSF combined with low intraocular per year is 0.9 per 100,000 people in the pressure or low perfusion pressure can Optic disc edema caused by an increase general population and 3.5 per 100,000 result in optic nerve edema.1 Increased in intracranial pressure is known as in women 15-44 years of age.1 intracranial pressure and resulting optic papilledema. Papilledema is the hall- 1 nerve edema damage the optic nerve by mark ophthalmoscopic sign of IIH. Cerebrospinal fluid, optic nerve: basic Stereoscopic disc viewing such as with review disruption of axonal transport, intra- neuronal ischemia or a combination of fundus biomicroscopy is essential to The brain, its blood supply and the both.1 avoid missing early papilledema. Ab- CSF are maintained within the skull. sence of a previously documented ve- Because the skull is made of bone and is There are several hypotheses of mecha- nous pulse or inability to induce a ve- nonflexible, a delicate balance must be nisms for the increase in intracranial nous pulse can also be a helpful sign. A maintained between all the structures pressure in IIH. They include increased useful grading scheme for papilledema within the skull. CSF is a clear, colorless brain water content, increased CSF was devised in 1982 by Frisen and mod- liquid, which is mainly produced in the production, reduced CSF drainage, in- ified in 2010 by Scott.22 The Modified choroidal plexus within the ventricular creased cerebral venous pressure and, Frisen Scale grades papilledema from system of the brain.8 CSF resides in the more recently, connections between grade 0 (normal) to grade 5 (severe). CSF space and the nasal lymphatic sys- space between the arachnoid mater and 5 Grade 1 is considered minimal with a the pia mater, the subarachnoid space.8 tem. The most supported hypothesis C-shaped peripapillary ring of edema for increased pressure is reduced CSF 22 The CSF provides nutrients, aids in 1 and nasal disc margins obscured. waste removal, maintains chemical sta- absorption. Reduced absorption may Grade 2 (low degree) is character- bility and cushions the brain.8 The CSF be secondary to dysfunction of the ab- ized by a circumferential peripapillary is produced at a rate of half a liter per sorptive mechanism of the arachnoid ring with nasal disc margin elevation granulations or through the extracra- 22 day and is turned over several times 12 and temporal disc margins obscured. per day.8 A steady state must be main- nial lymphatics. Grade 3 (moderate) is obscuration of at tained between production and drain- Clinical features least one major vessel as it passes over 22 age of CSF to maintain an appropriate Common clinical features of IIH are: the disc with elevation of disc borders. amount of fluid within the skull. Grade 4 (marked) is total obscuration • Headaches 22 The CSF circulates from the site of for- of a vessel at its origin. Grade 5 (se- mation to the subarachnoid space and Ninety to 94% of patients with IIH vere) is characterized by total obscura- present with headaches.13-17 The head- tion of all vessels both on the disc and interpeduncular and quadrigeminal 22 cisterns.9 Drainage of fluid involves ab- aches are described by patients as se- leaving the disc. 1 sorption into the venous system, which vere, “the worst headache of my life.” • Vision loss occurs mainly through the arachnoid The is generalized, pulsatile, may awaken the patient from sleep, usu- The consequences of papilledema can villi in the brain and the arachnoid result in vision loss. According to Cor- granulations.9 This occurs via two path- ally lasts for hours and is worse in the 18 bett et al., vision loss is the main mor- ways: active transport through the cells morning. Occasionally patients re- 3 18 bidity associated with IIH. Visual field of the arachnoid granulations into the port neck, back or shoulder pain. The headache may be associated with nau- defects found in IIH are directly re- dural venous sinus or transport between lated to papilledema and are similar to the cells of the arachnoid granulations.9 sea and vomiting, with vomiting being 1 visual field defects that occur in other CSF absorption can also occur through less common. 1 optic neuropathies. The most common the extracranial lymphatic system. • Transient visual disturbances defects are enlargement of the physi- The optic nerve is considered part of Transient blurred vision or other visual ological blind spot and an inferior nasal the central .10 Retinal disturbances that usually last less than step.1 Other possible defects include ar- ganglion cells exit the eye at the lamina 30 seconds are reported in 68% of pa- cuate defects, generalized constriction cribrosa and acquire a myelin sheath to tients.1,17 The symptoms may be mon- or depression of isopters, paracentral form the optic nerve.10 The optic nerve ocular or binocular and are believed to and temporal wedge defects.21 sheath is comprised of fibrous tissue be related to transient ischemia second- This type of vision loss is indicative of and has a limited ability to expand.11 ary to increased tissue pressure.19 damage at the level of the optic disc The optic nerve and fibrous tissue run rather than posterior to the disc.1 Al- • Tinnitus within the subarachnoid space.11 though there is some evidence that vi- Intracranial pulsatile noises are reported The subarachnoid space around the op- sion loss corresponds to the severity of

Optometric Education 121 Volume 37, Number 3 / Summer 2012 disc edema, there is considerable varia- pressure of greater than 250 mm of wa- rooms or departments are an excellent tion between individuals.1 Visual field ter is considered elevated, and readings resource because most are available 24 loss leads to blindness in 5% of cases.1 of 200-250 mm of water are borderline hours a day, 7 days a week, staffed with 23 • Other and not diagnostic. Normal CSF com- trained personnel, and usually able to position must be established; therefore, perform imaging in a rapid manner. Photopsia (54%), retrobulbar pain an analysis of fluid to rule out other • Management of IIH (44%), horizontal (33%), and conditions is done. sixth-nerve palsies (10-20%) are also re- Due to a paucity of evidence related to ported in the literature.17 Patients with There are several medical conditions treatment options, there are no specific IIH may be asymptomatic.18 and medications that mimic IIH. These treatment recommendations.18 Man- conditions all have an associated cause Diagnosis and diagnostic action agement of IIH involves management for the intracranial hypertension. The of symptoms and the prevention of vi- The diagnosis of IIH is a diagnosis of literature is inconclusive about the sion loss.1 exclusion. In 2002, Friedman and Ja- strength of the relationship between these conditions and IIH.1 The general LP performed as part of the diagnos- cobson updated the criteria that must 26 be met to make the diagnosis of IIH. categories for these associations are: de- tic workup can often be therapeutic. creased flow through arachnoid granu- A single LP can offer a lasting decrease The criteria include: “elevated intracra- 26 lations, obstruction to venous drainage, in CSF pressure in some patients. nial pressure measured in the lateral de- 27,28 cubitus position, normal CSF compo- endocrine disorders, nutritional disor- Weight loss has been demonstrated sition, no evidence of , ders and medications.1 All patients sus- to be an effective treatment for IIH. mass structural or vascular lesion on pected of having IIH must be screened Only a moderate reduction in weight for secondary causes before a definitive loss, 5-10% of total body weight, is MRI or contrast-enhanced computed 28 tomography (CT) for typical patients diagnosis can be made. needed. Therefore, all obese patients with IIH should be encouraged and and magnetic resonance (MR) venog- Management raphy for all others and no other causes monitored for weight loss. of intracranial hypertension identified. • Optometric management of Drugs that reduce CSF production are If symptoms or signs present, they may papilledema also used for treatment. The carbonic only reflect those of generalized intrac- A diagnosis of papilledema in a symp- anhydrase inhibitor acetazolamide is ranial hypertension or papilledema.”23 tomatic or asymptomatic patient re- the most commonly used.18 The mode and LP with the patient quires immediate action. Many system- of action of the drug involves decreasing in the lateral decubitus position are the ic conditions can result in papilledema. sodium ion transport across the choroi- (Table 7) Because some of these condi- dal epithelium, which causes a decrease initial tests done in determining the 18 diagnosis. Physical examination with tions can be life- or sight-threatening, in CSF. The efficacy of acetazolamide a quick and accurate management plan in treating the condition is still being blood testing and other tests to rule out 1 secondary causes of intracranial hyper- is imperative. Appropriate optomet- studied. The starting dose is 250 mg tension may also be performed. ric testing involves a detailed medical twice a day and is steadily increased to history, including use of medications, 1000-2000 mg/day.18 Common side Neuroimaging can be done with CT blood pressure measurement, visual effects of the drug include changing scans, MRI and MR venography. Al- acuity, and color vision assess- the of food, anorexia, tingling in though CT scans are adequate, MRI ment as well as fundus examination fingers, toes and perioral region, and is more specific in detecting causes of with stereoscopic lenses.25 Emergency malaise.1 Furosemide, which works by 23 increased intracranial pressure. MR imaging of the head is also warranted diuresis and reducing sodium transport venography is useful in differentiating and should be arranged by the exam- into the brain, can also be used.1 between a diagnosis of IIH and venous ining eye doctor.25 Hospital emergency sinus occlusions.24 LP is the definitive test for determin- ing an increase in CSF pressure.23 Neu- Table 7 roimaging of the brain is usually done Examples of Systemic Conditions that Can Result in Papilledema25 before LP to rule out space-occupying 18 lesions or other causes of papilledema. Space-occupying lesions Intracranial tumors The LP is done in the lateral decubitus Subdural or epidural hematomas position with the legs as relaxed as pos- Subarachnoid hemorrhage sible. LP in other positions can result Infection Brain in misleading readings.18 CSF pressure can fluctuate throughout the day or be Other Aqueductal stenosis producing hydrocephalus elevated in a patient with anxiety from Sagittal sinus 23 pain or crying. Therefore, repeat mea- Arteriovenous malformation surements may be needed to confirm a Uncontrolled hypertension diagnosis. Increased intracranial hypertension It is generally agreed that opening CFS

Optometric Education 122 Volume 37, Number 3 / Summer 2012 Optic nerve sheath fenestration and CSF shunting procedures can be per- Table 8 formed in cases of progressive or signifi- Parts of Analysis32 cant visual field loss. These procedures have potential complications and can PARTS OF ANALYSIS DEFINITION 29,30 Purpose Your purpose is your goal, your objective, what you are trying to be less effective over time. accomplish. Careful follow-up of patients with IIH Question The question lays out the problem or issue and guides thinking. is essential. Follow-up schedules are de- Information Information includes the facts, data, evidence or experiences we termined by severity of signs and symp- use to figure things out. 18 toms. Follow-up assessment should Inferences Inferences are interpretations or conclusions you come to. Infer- include visual acuity, color vision, optic ring is what the mind does to figure something out. disc evaluation and visual fields with Assumptions Assumptions are beliefs you take for granted. either an automated or Goldmann pe- Concepts Concepts are ideas, theories, laws, principles or hypotheses we rimeter.18 use in thinking to make of things. Point of view Point of view is literally the place from which you view some- Teaching methodology and critical thing. thinking concepts Implications Implications are the things that might happen if you decide to do The teaching of this case can occur in something. many different formats. Faculty may consider a problem-based teaching Table 9 method where only small pieces of in- Recommended Readings on Critical Thinking formation are given out at a time with the students identifying information 1. Hawkins D, Paul R, Elder L. The Thinker’s Guide to Clinical Reasoning. Dillon Beach, California, needed, problems to be solved, etc. Foundation for Critical Thinking Press; 2010.

Alternatively, a case-analysis method 2. Facione NC, Facione PA. Critical Thinking and Clinical Reasoning in the Health Sciences. Millbrae: could be used where students are given California, Academic Press; 2008. the case in its entirety followed by an 3. Nosich G. Learning to Think Things Through. Upper Saddle River, New Jersey, Pearson Prentice in-depth discussion of the material. Hall; 2009 Throughout the teaching of this case, students should be challenged with identifying and using critical think- Table 10 ing concepts. Clinical decision-making SPIKES Model for Delivery of Bad News34 involves the use of clinical knowledge, Six steps of the SPIKES model skills, experience and critical thinking. Setting Be prepared; rehearse what you are going to say; arrange for Critical thinking provides a strategy for privacy; with the patient’s permission involve a significant other; accurate, thorough and efficient think- sit down; connect with the patient; manage time constraints. Patient’s Use open-ended questions to assess what the patient per- ing, which utilizes analysis, evaluation ceives. and reflection of thinking.31 Analy- Obtaining the patient’s invitation How does the patient want to receive the information? sis of thinking divides thinking into smaller parts with a focus on purpose Knowledge and information Use vocabulary that the patient understands, non-technical words; avoid excessive bluntness; give information in small of thinking, questions, information, chunks; check to make sure the patient is understanding the inferences, assumptions, concepts, im- information. plications and point of view.31 Evalua- Addressing the patient’s emotions Identify the emotions the patient is feeling; identify the reason with empathetic responses for the emotion. tion of thinking involves assessing the Strategy and summary Summarize the information; make a plan for the future; share clarity, accuracy, precision, relevance, the decision-making with the patient. depth and breadth of thinking.31 Table 8 defines the concepts of the analysis of critical thinking. Delivery of bad or upsetting news is given which conveys to an individual 33 Critical thinking concepts should be The literature cites many models for fewer choices in his or her life.” The applied to all aspects of the clinical en- delivering bad news and for teaching SPIKES model, which is used in many counter, case history, physical examina- students how to do it. It is beyond the medical settings and is appropriate for scope of this paper to provide a review optometric settings, is one model for tion, determination of diagnostic test- 34 ing and patient management to ensure of all models used for the delivery of bad the delivery of bad news. It is charac- the highest level of patient care. news. Bor et al. provide a useful defi- terized by: setting, patient’s perception, nition of bad news: “situations where invitation, knowledge, empathizing and For more in-depth information on the 34 there is either a feeling of no hope, a summary/strategy. Table 10 provides topic of critical thinking, Table 9 con- additional information on the SPIKES tains a list of recommended readings threat to a person’s mental or physical well-being, a risk of upsetting an es- model. Teaching strategies may involve: that are appropriate for both students lecture/didactic approach, small group and educators. tablished lifestyle, or where a message Optometric Education 123 Volume 37, Number 3 / Summer 2012 discussion, role-playing with peers or standardized patients or observation of 35 Table 11 skilled clinicans. Classification of Hypertensive Retinopathy Management of systemic hypertension and Blood Pressure Readings37,38

Hypertension or high blood pres- Acute (severe) HTN HTN HTN sure is a common condition affecting Urgency Emergency more than 60 million people in the Blood pressure >180/110 >180/120 >180/120 United States.36 Retinal findings asso- measurement Clinical eye findings Mild hypertensive Moderate hypertensive Moderate hypertensive ciated with hypertension, along with retinopathy, characterized retinopathy, retinopathy with disc in-office blood pressure measurements, by generalized arteriolar characterized by edema, characterized narrowing, focal arteriolar hemorrhages, retinal by mild and moderate can be useful in the management of narrowing, A/V crossing aneurysms, cotton wool findings in addition to patients with hypertension. Accurate changes spots, hard exudates optic nerve swelling blood pressure readings involve a pa- tient quietly sitting in a chair for at least 5 minutes with the arm supported at level, an appropriate size cuff of gathering information, formulating of differential diagnoses. At this time, and at least two blood pressure mea- working hypotheses and the question- blood pressure readings were obtained surements.36 Common retinal findings ing of patients to generate an initial and revealed elevated readings (right associated with hypertension include: differential diagnosis. The case history arm 180/115 mmHg; left arm 160/120 generalized arteriolar narrowing, focal is an ideal time to utilize the critical mmHg). arteriolar narrowing, artery/vein (A/V) thinking concepts of evaluation, clarity, Evaluating evidence is part of criti- crossing changes, hemorrhages, retinal accuracy etc., to ensure completeness cal thinking. True disc edema should aneurysms, cotton wool spots, hard of information. In this case, the use of 37 not be inferred until all the evidence is exudates and optic nerve swelling. electronic medical records facilitated evaluated. Conditions that could result The Seventh Report of the Joint National the accuracy, depth and precision of in- in pseudo disc edema must be consid- Committee on Prevention, Detection and formation concerning current medical ered. Pseudo disc edema can be caused Treatment of High Blood Pressure (JNC- diagnoses, medications, height, weight by or congenitally 7) identified hypertensive crisis as- ei and blood pressure readings. For this anomalous disc.25 The patient’s prior ther hypertensive urgencies or emer- information, we did not have to rely on eye examination records were not avail- gencies.36 Hypertensive emergency, a the patient as a historian. able nor were any imaging techniques condition previously known as malig- Initially, the patient’s weight, gender available to rule out disc drusen. How- nant hypertension, requires immediate and age did not generate any addi- ever, the fundus findings and hyperemic medical attention with control of blood tional differentials. The rising preva- color of the discs provided supporting pressure within 2-6 hours.37 Hyperten- lence of obesity is a public healthcare evidence for true disc edema. sive urgencies require a timely and ap- issue, which can impact the practice of The fundus findings necessitated a revi- propriate referral with blood pressure optometry. As optometrists see more sion to the initial differential diagnosis control within 24-72 hours. Optic disc obese patients, the implications of ocu- list. What differential diagnosis should edema is the hallmark sign of hyperten- lar consequences from obesity will need 37 now be considered? If the assumption is sive emergency. Table 11 identifies to be considered by eyecare practitio- made that only one condition is causing the classification of hypertensive retin- ners. In this case, the patient presented the fundus findings, then severe hyper- opathy. with several risk factors for IIH. The tensive retinopathy vs. other causes of headache complaint would not have Discussion optic disc edema need to be considered. been considered a risk factor because Severe hypertensive retinopathy is sup- The patient’s initial presenting- com it did not fit the typical profile of the ported by the fundus findings, medical plaint of “eye fatigue” along with rel- IIH patient. Did the clinician make an history and blood pressure measure- evant medical information generated assumption that the patient’s weight, ments. Hypertensive urgency vs. emer- a differential diagnosis of dry eye syn- gender and age did not have any impact gency needs to be evaluated because of drome (primary or secondary), un- on the eyes? the implications in the management corrected refractive error, specifically The exam proceeded, guided by the plan. The blood pressure measurements hyperopia, binocular/accommodative initial list of differential diagnoses. could indicate either category, but the anomalies or asthenopia related to ex- The signs from the retinal examination presence of optic disc edema would in- cessive computer use. The patient was (A/V crossing changes, retinal vein en- dicate a hypertensive emergency. also considered at risk for hypertensive gorgement, flame-shaped hemorrhages Optic disc edema can potentially indi- retinopathy secondary to her history of and elevated, blurred and hyperemic poor compliance and control. This was cate a life-threatening condition. The discs) along with the patient’s diagno- signs associated with optic disc edema a reasonable list of possible causes for sis of hypertension and history of non- the patient’s entering chief complaint. are: retinal hemorrhages, often flame- compliance with hypertensive medica- shaped, dilated tortuous retinal veins The case history involves the process tions demanded a revision to the list with normal pupillary response and

Optometric Education 124 Volume 37, Number 3 / Summer 2012 color vision.25 Therefore, other causes edema could have been caused by the been established, the patient was treat- of optic disc edema, such as a space-oc- uncontrolled hypertension, neuroimag- ed with the medication.5 The medica- cupying lesion, infection or IIH, must ing and additional testing were needed tion was discontinued secondary to the be considered. The patient did not pres- to rule out the other possibilities. side effects. The patient is currently -do ent with any other systemic symptoms, Although decision-making for appro- ing well and is being managed by the such as fever, malaise, weakness or dis- priate medical diagnostic testing is ulti- neuro-ophthalmologist and PCP with orientation. The patient’s weight, age mately the responsibility of the medical weight control and monitoring. Fol- and gender are consistent with IIH. provider, as optometrists and primary low-up assessment includes visual acu- The astute clinician must consider all care eye providers, it is our responsibil- ity, color vision, optic disc evaluation possibilities when analyzing informa- ity to communicate with other health- and automated visual fields. tion related to the determination of care professionals and properly educate Optometrists play an important and the differential and final diagnoses. the patient. What diagnostic testing vital role in the delivery of eye care. The retinal findings and blood pres- was needed to make the diagnosis? Optometrists in some circumstances sure readings along with the patient’s After consultation with the physician work under time constraints and pro- history of longstanding hypertension at the ER of a nearby hospital, it was ductivity quotas. What level of involve- with moderate compliance and control determined that neuroimaging would ment is expected for the primary care could lead to a premature conclusion be performed the next morning. Both optometrist? Is it sufficient to make the that the findings were secondary to un- a CT scan and MRI were available. appropriate referral, communicate im- controlled hypertension. The analysis A CT scan uses X-rays to show cross- pressions and educate the patient, or is of information involved in coming to a sectional images of the body.39 High- it our ethical duty to oversee the care diagnostic conclusion involves not only energy radiation can potentially cause of the patient after he or she leaves the demonstrating support for a particular damage to DNA and therefore increase office? The primary care optometrist disease/condition but also ruling out a patient’s lifetime risk of cancer.39 MRI played a significant role in overseeing the other possible disorders/conditions. uses strong magnetic fields and radio the care of this patient after the initial This emphasizes the importance of the waves to image the body. MRI does referral to urgent care and the ER. By differential diagnosis list. If other pos- not use ionizing radiation and there are staying in constant communication sibilities are never considered, there is no known harmful side effects.40 MRI with the patient, the optometrist was a risk of noninclusion in the thinking was chosen as the initial neuroimag- able to be a resource for the patient, leading to the final diagnosis. The im- ing test for the patient because MRI is facilitate her care and offer a support plications of this incomplete thinking more specific in identifying causes of system for the patient. Primary care could have put this patient at enormous increased intracranial pressure and does optometrists provide a valuable link be- risk because the other possibilities were not involve exposure to radiation. The tween the patient and a specialist. life- or sight-threatening. additional use of MR venography was If a patient is lost to follow-up, the cli- The elevated blood pressure and the under the discretion of the ER doctor. nician is unable to intervene and help disc edema needed to be immediately If neuroimaging was negative, a lum- the patient. At several points in this addressed. The role of the optometrist bar spinal puncture would be done to case there were opportunities for the is coordination of care, appropriate confirm or rule out IIH. LP is generally patient to have been lost to follow-up. and timely referral(s) and providing recognized as a safe procedure.41 Pos- What was done to avoid this? The more appropriate patient education. The op- sible side effects include headache, back complex and serious a patient’s diagno- tometric management of this patient discomfort, or brain stem her- sis and follow-up plan, the greater the involved the immediate referral for niation if a space-occupying lesion is consequences of losing the patient to control of blood pressure and imaging present.41 follow-up. The patient may get frus- to determine the cause of the bilateral Diagnostic testing revealed normal neu- trated with the process of going to ad- disc edema. roimaging, normal CSF composition, ditional doctors and to different places The urgent care department of the opening CSF pressure of 320 mm of for follow-up care. The patient may health center was contacted and advised water and closing pressure of 150 mm not feel comfortable with the person to of the case. The urgent care department of water. Physical examination and case whom she has been referred and may was able to see the patient immediately history of the patient did not reveal any not fully understand the importance of for management of the blood pressure. other causes of elevated CSF pressure. the testing and treatment that has been After review of the patient’s record and The elevated opening pressure along given by someone other than the origi- physical examination, the urgent care with the negative findings on neuroim- nal practitioner whose care she sought. physician felt the patient’s blood pres- aging and normal CSF composition ex- The patient may simply be overwhelmed sure could be controlled on an outpa- cluded other possibilities and met the by the prospect of a serious health cri- tient basis with oral medications. If criteria for the diagnosis of IIH. sis and decide to ignore it. In this case, blood pressure control involved intra- the patient was frustrated with lack of The LP may have been sufficient to follow-up by her primary care physi- venous medications or in-patient hospi- bring down the CSF pressure. Although talization, the patient would have been cian and was ill from side effects of the the effectiveness of acetazolamide as a medication but worried about giving it referred that night to the emergency treatment of this condition has not yet department. Although the optic disc up and losing vision. The fact that the

Optometric Education 125 Volume 37, Number 3 / Summer 2012 primary care optometrist was willing to a diagnosis. The patient was reassured 2003;326(7390):613-614. give the patient her cell phone number as much as possible and every effort 5. Bruce BB, Biousse V, Newan NJ. and made the effort to see that things was made to provide empathic care. Update on idiopathic intracranial were proceeding as they should have, We acknowledged how stressful and hypertension. Am J Ophthalmol. meant that the patient was not lost to scary it must be for a patient to wait 2011;152(2):163-169. follow-up care. The optometrist used for the completion of tests before a fi- 6. Friesner D, Rosenman R, Lobb the characteristics of respect for the nal diagnosis could be made. In some BM, Tanne E. Idiopathic intracra- patient, concern about the outcome, circumstances, seeking additional help nial hypertension in the USA: the empathy, understanding and sensitivity from mental healthcare providers may role of obesity in establishing prev- to provide this patient with appropriate be necessary. alence and health care cost. Obes 42 care. Having access via cell phone to the Rev. 2011;12(5):372-308. Understanding the patient’s point optometrist was very reassuring to the 7. Bruce BB, Preechawat P, Newan of view is an important component patient and provided continuity of NJ, Lynn MJ, Biousse V. Racial in providing compassionate and ap- care. The patient wasn’t able to reach differences in idiopathic intrac- propriate care. The patient had many her PCP and did not feel appropriate ranial hypertension. Neurology. questions and was visibly upset by the time was given to question the neu- 2008;70(11):861-867. examination findings. Communica- rologist. We can also assume that suf- 8. Nolte J. The : an in- tion with the patient was potentially ficient doctor/patient trust was also not troduction to its functional anato- hindered by the patient’s reaction to established with the neurologist. These my: 6th edition. Philadelphia, PA: the findings. The patient was scared be- circumstances led to a communication Mosby Elsevier; 2009, p.105-110 cause her findings were unexpected and breakdown, unnecessary stress and the 9. Moore KL, Dalley A, Agur A. she felt well. As optometrists, we have continuation of medication that was Clinically oriented anatomy: 6th a duty to inform our patients of their producing undesirable side effects. edition. Philadelphia, PA: Wolters healthcare status, including appropri- Primary care optometrists can provide Kluwer, Lippincott Williams, & ate procedures and the risks/benefits an important resource in navigating Wilkins; 2010, p.879-882. of those procedures.43 Additionally, we through the healthcare system. 10. Nolte J. The human brain: an in- must make the effort to ensure that the troduction to its functional anato- patient has a reasonable understand- Conclusions my: 6th edition. Philadelphia, PA: ing of the information presented.43 We Mosby Elsevier; 2009, p.438. The primary care optometrist played a 11. Hayreh SS. Pathogenesis of optic asked the patient to repeat back to us in significant role in the coordination of her own words the information we had disc edema in raised intracranial care, as a resource for the patient and in pressure. Trans OpthalmolSoc UK. given her. Our concern was that her the delivery of patient education. This emotional state would impact her un- 1976;96:404-407. case highlights the importance of accu- 12. Boulton M, Armstrong D, Fless- derstanding and compliance. This case rate and thorough thinking in analyzing presented a challenge because full dis- ner M, et al. Raised intracranial information and patient management. pressure increases CSF drainage closure of exam findings was viewed as Interprofessional communication and potentially causing the patient a great through arachnoid villi and ex- communication between patient and tracranial lymphatics. AM J Phys- deal of stress and possibly impacting doctor is also a major component in her already high blood pressure. There iol. 1998;275(3):889-896. facilitating the care of the patient. The 13. Wall M. The headache profile of id- is always a careful balancing act that the majority of this patient’s care was under primary care optometrist must perform iopathic intracranial hypertension. the supervision of other medical profes- Cephalalgia. 2002;10:331-335. to give the patient enough information sionals, but despite this involvement the to describe the seriousness of the situa- 14. Redhakrishnen K, Ahloskog E, optometrist was a key professional in Cross SA, Kurland LT, O’Fallon tion without unnecessarily scaring the the successful care of this patient. patient. However, it is the optometrist’s WN. Idiopathic intracranial hy- pertension (pseudo tumor cerebri): ethical obligation to inform the patient References of all the exam findings. description epidemiology in Roch- 1. Wall M. Idiopathic intracra- ester, Minnesota 1976-1990. Arch Delivering bad or potentially upsetting nial hypertension. NeurolClin. Neurol. 1993;50:78-80. news to a patient is difficult for clini- 2010;28(3):593-617. 15. Rush JA. Pseudotumorcerebri: cians and students. The patient was 2. Krajewski K, Gurwood S. Idio- clinical pitfall and visual outcome informed of the exam findings in the pathic intracranial hypertension: in 63 patients. Mayo Clinic Proc. exam room. The patient was alone and pseudo tumor cerebri. Optometry. 1980;55:541-546. did not want to call a family member. 2002;73:546-552. 16. Wall M, George D. Idiopathic in- The patient was informed of the swol- 3. Corbett JJ, Savino PJ, Thomp- tracranial hypertension (pseudo tu- len optic nerves and the potential im- son HS, et al. Visual loss in pseu- mor cerebri), a perspective study of plications of the condition, from the do tumor cerebri. Arch Neuol. 50 patients. Brain. 1991;114:155- more benign to the life-threatening. It 1982;39:461-474. 180. was clearly stated that additional test- 4. Digre KB. Not so benign in- 17. Giuseffi V, Wall M, Siegel P, et al. ing would need to be done to confirm tracranial hypertension. BJM. Symptoms and diseases associa-

Optometric Education 126 Volume 37, Number 3 / Summer 2012 tions in idiopathic intracranial hy- of idiopathic intracranial hyper- 39. Computed Tomography (CT). pertension (pseudo tumor cerebri): tension (pseudo tumor cerebri). United States Food and Drug Ad- a case control study. Neurology. Opthalmology. 1998;105:2313- ministration. Silver Spring, Mary- 1991;41:239-244. 2317. land. C2010[cited 2012 Mar 14]. 18. Dhungana S, Sharrack B, Woodroof 29. Spoor TC, Ramocki JM, Madion Available from: http://www.fda. N. Idiopathic intracranial hyper- MP, et al. Treatment of pseudo gov/Radiation-EmittingProducts/ tension. ACTA Neurol Scand. tumor cerebri by primary and RadiationEmittingProductsand- 2010;12(2):71-82. secondary optic nerve sheath de- Procedures/MedicalImaging/Med- 19. Sadun A, Currie J, Lessell S. Tran- compression. Am J Ophthalmol. icalX-Rays/ucm115317.htm#. sient visual obscurations with el- 1991;112:177-185. 40. MRI Magnetic Resonance Imag- evated optic discs. Ann Neurol. 30. Eggenberger ER, Miller N, Vitale ing. United States Food and Drug 1984;16:489-494. S. Lumboperitoneal shunt for the Administration. Silver Spring, 20. Farb RI, Vanek I, Scott JN, et al. treatment of pseudo tumor cerebri. Maryland. [cited 2012 Mar 14]. Idiopathic intracranial hyperten- Neurology. 1996;46:1524-1530. Available from: http://www.fda. sion: the prevalence and morphol- 31. Paul R, Elder L. Introduction. In R. gov/Radiation-EmittingProducts/ ogy of sinovenous stenosis. Neurol- Paul and L. Elder (Eds.), Criti¬cal RadiationEmittingProductsand- ogy. 2003;60:1418-1428. thinking: Tools for taking charge Procedures/MedicalImaging/ 21. Rowe FJ, Sarkies NJ. Assessment of your learning and your life. ucm200086.htm#. of visual function in idiopathic in- Columbus, OH; Pearson Prentice 41. Mayo foundation for medical tracranial hypertension: a prospec- Hall, 2006, p.xvii-xxx. education and research. Mayo tive study. Eye. 1998;12:111-118. 32. A miniature guide to the founda- Foundation for Medical Educa- 22. Scott CJ, Kardon RH, Lee AG, tion of analytic thinking [internet]. tion and Research Rochester. Frisen L, Wall D. Diagnosis and The Foundation for Critical Think- Minnesota. [cited 2012 Mar grading of papilledema in patients ing. Dillion Beach, California. 14]. Available from: http://www. with raised intracranial pressure us- c2005 [cited 2012 Feb 27]. Avail- bing.com/health/article/mayo- ing optical coherence tomography able from: http://www.criticalth- MAMY00982/Lumbar-puncture- vs clinical expert assessment using inking.org/ctmodel/logic-model1. spinal-tap?q=lumbar+puncture. a clinical staging scale. Archives of htm. 42. Ettinger, Ellen R. Professional Ophthalmology. 2010:128(6):705- 33. Bor R, Miller R, Goldman E, Communications in Eye Care. 11. Scher I. The meaning of bad news Boston: Butterworth-Heinemann, 23. Friedman D, Jacobson D. Diag- in HIV disease.Couns Psych Q. 1994, p. 78-90. nostic criteria for idiopathic intrac- 1993;6:69-80. 43. AOA standards of professional ranial hypertension. Neurology. 34. Baile W, Buckman R, Lenzia R, care. C2011 [cited 2012 Mar 2002;59:1492-1495. Globera G, Beale E, Kudelka P. A 14]. Available from: http://www. 24. Purvin VA, Trobe JD, Kosmorsky six- step protocol for delivering bad aoa.org/documents/standards-of- G. Neuro-opthalmic features of news: application to the patient professional-Conduct_Adopted- cerebral venous obstruction. Arch with cancer. The Oncologist. Au- June-2011.pdf. Neurol. 1995;52:880-888. gust 2000;5(4):302-311. 25. Kunimoto D, Kanithkan K, Makar 35. Rosenbaum M, Ferguson K, Lobas M. Editors.The Wills Eye Manual J. Teaching medical student and 4th Edition. Philadelphia, Penn- residents skills for delivering bad sylvania. Lippincott Williams & news: a review of strategies. Aca- Wilkins; 2004, p.223-226. demic Medicine. 2004;79(2):107- 26. De Simone R, Marano E, Fiorillo 117. C, et al. Sudden re-opening of col- 36. Chobanian AV, Bakris HR, et al. lapsed transverse sinuses and long- The seventh report of the joint standing clinical remission after a national committee on preven- single lumbar puncture in a case of tion, detection, evaluation, and idiopathic intracranial hyperten- treatment of high blood pres- sion. Pathogenetic implications. sure. The JNC 7 Report. JAMA. Neurol Sci. 2005;25(6):342-344. 2003;289(19):2560-2572. 27. Kupersmith MJ, Gamell L, Turbin 37. Meetz R, Harris T. The optom- R, Peck V, Spiegel P, Wall M. Ef- etrist’s role in the management of fects of weight loss on the course hypertensive crisis. Optometry. of idiopathic intracranial hyper- 2011;82:108-116. tension in women. Neurology. 38. Hammond S, Wells JR, Marcus 1998;50:1094-1098. DM, et al. Ophthalmoscopic find- 28. Johnson LN, Krohel GB, Madsen ings in malignant hypertension. J RW, et al.The role of weight loss Clin Hypertension. 2006;8:221- and acetazolamide in the treatment 230.

Optometric Education 127 Volume 37, Number 3 / Summer 2012