UMEM Educational Pearls

Category: Neurology

Title: Visual Loss in Idiopathic Intracranial Hypertension

Keywords: pseudotumor cerebri, visual loss, shunt (PubMed Search)

Posted: 11/27/2014 by Danya Khoujah, MBBS
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There are a few available options for treatment of visual loss due to idiopathic intracranial hypertension (IIH). The Idiopathic Intracranial Hypertension Treatment Trial (IIHTT), the first randomized, prospective, placebo-controlled trial for the treatment of patients with visual loss from IIH, which results were published earlier this year, provided substantial evidence for the first 2 options.

1. Weight loss

2. Carbonic anhydrase inhibitors, such as Acetazolamide

3. Therapeutic lumbar puncture (reserved for pregnant patients or for occasional flare-ups)

4. Surgery:

a. Optic nerve sheath fenestration (ONSF): visual acuity and fields improve in most cases, but symptoms may recur. Benefit? No hardware!

b. Shunts: ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts are the most frequently used. No clear benefit for one over the other. VP shunts may be programmable.

c. Cerebral venous stenting: endovascular stenting of the transverse sinus may improve the symptoms in some people.

BONUS PEARL: The headache does not correlate with the lumbar opening pressure, degree of papilledema or amount of visual loss. None of the above-mentioned management strategies is meant for the treatment of the headache alone. For that, medical management with standard symptomatic treatments, avoiding opiates and barbiturates, is recommended. Surgery is not recommended for headache alone.


Friedman DI. Papilledema and idiopathic intracranial hypertension. Continuum. 2014 Aug;20(4 Neuro-ophthalmology)