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  • Diagnostic uncertainty due to optic disc drusen

    By Mike Vaphiades, DO
    Neuro-Ophthalmology/Orbit

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    This article presents the case of an 80-year-old woman who developed both swollen optic nerves and optic nerve head hemorrhages associated with optic disc drusen. Chronic papilledema was a diagnostic consideration and neurologic evaluation was undertaken but was negative, leading to diagnostic uncertainty.

    The presence of optic disc drusen almost always obviates the need for further testing. Optic disc edema associated with optic disc drusen may occur in: 1) nonarteritic anterior ischemic optic neuropathy, 2) raised intracranial pressure, and 3) association with hemorrhagic events. Hemorrhage associated with optic disc drusen have been described in: 1) small nerve fiber hemorrhages localized to the optic disc, 2) optic nerve head hemorrhages extending into the vitreous, and 3) subretinal peripapillary hemorrhages with or without associated choroidal neovascularization. 

    The patient had a history of chronic anxiety for which she was taking sertraline. Visual acuity was 20/25 bilaterally, and color vision and pupillary reactions were normal.

    Funduscopy revealed that both optic discs contained drusen and were edematous with peripapillary hemorrhages. Automated visual fields demonstrated peripheral nerve fiber bundle defects in each eye. B-scan ultrasound showed prominent optic nerve drusen bilaterally. Fluorescein angiography showed the presence of optic disc drusen and dye leakage in the late phases of the angiogram, more of the right disc than of the left disc.

    Since the patient had good visual acuity and intact color vision, increased intracranial pressure was suspected. However, MRI of the brain showed only white matter ischemic changes consistent with the patient's age. Complete blood count, metabolic panel including blood glucose, and Westergren sedimentation rate were normal. Lumbar puncture showed an opening pressure of 17 cm H20 with normal cerebrospinal fluid analysis.

    The patient was prescribed gabapentin. Examination seven months later showed resolved optic disc edema and peripapillary hemorrhage OD and nearly resolved peripapillary hemorrhage OS.