Visual loss due to intracranial hypotension in a patient with optic nerve head drusen

A 58 year old woman with a history of ONH drusen complained of worsening vision OU and headaches. Initial examination revealed visual acuity was 20/60 OD and 20/30 OS, decreased color plates OD, constricted visual fields to confrontation OU, and no afferent pupillary defect. Optic nerves appeared pallorous with obvious ONH drusen. Three months later the visual acuity was noted to be hand motions OD and 20/200 OS. Confrontation visual at that time revealed hand motions centrally OD and count fingers centrally OS. No color plates were detected OU. Optic nerve exam was unchanged. Further testing with MRI of the brain and orbits revealed meningeal enhancement, transtentorial herniation of the left temporal lobe, cerebellar herniation through the foramen magnum, and chiasmal sagging with venous congestion through the optic canals. These findings, together with the patients headache were consistent with intracranial hypotension. MRV did not show any sinus thromboses. Whole spine MRI and CT myelography failed to show any dural tears. Opening pressure was not checked at the time of myelography, but the CSF consistency was normal. The patient was treated with lumbar epidural blood patching. The patients headache resolved the same day as the procedure. On follow up, the headaches resolved and the vision improved to 20/800 OD and 20/70 OS. Repeat MRI of the brain revealed resolution of the meningeal enhancement, chiasmal sagging, cerebellar herniation, and temporal lobe herniation.