NANOSNET

57 yo woman with DM, HTN, hypothyroid, afib, remote Lyme, remote meningitis experiencing TVOs OS for nearly 3 months.  Had first eye exam for this symptom a couple of weeks ago and found to have left disc edema.  I do not have records of that exam.

Sent to hospital.  Extensive inpatient workup summary:

• imaging- MRI brain/orbits, MRV, CTA head and neck all negative (I reviewed MRI images and agree)
• LP OP 12, CSF composition normal including cytology
• Labs- HIV, bartonella, Ehrlichia, RMSF, Lyme, ESR, CBC, CMP all negative or normal; CRP 10.1 (upper limit normal 9)

First saw her yesterday.  She has no symptoms other than occasional darkening of vision OS lasting seconds. Heavy snorer.  No meds of concern other than potentially Ozempic. Left disc edema (I have attached stereo photo from my exam) with normal acuity and perimetry.  RNFL OCT c/w disc edema.  No drusen. OCT macula, ganglion cell analysis normal. Right disc crowded.  

Is this impending NAION?  Not used to getting reports of TVOs in this circumstance. Suggestions for further workup.  Thanks in advance.

Right disc is crowded.  Left eye acuity and perimetry completely normal and she feels vision is normal other than during the TVOs.  Did not do color plates.  Lyme: 

This chemiluminescent assay detects IgM and IgG antibodies using a solid phase coated with Borrelia VlsE, variable major protein-like sequence, expressed antigens (B. burgdorferi and B. garinii) and Borrelia OspC, the outer surface protein (B. afzelii; crossreactive with B. burgdorferi).

Can Lyme cause disc edema without optic nerve dysfunction?

Original Message:
Sent: 07-22-2026 09:02
From: Scott Forman
Subject: help with disc edema case

Why would this be "impending" NAION. Is the other disk at risk? Color vision? field?

If the Lyme and other tic born dseases are "negative" is this by CDC Western blot which is only 25% positive? Does she have cognitive symptoms, arthralgias, etc ? How was Lyme treated in the past?

Scott Forman, MD

Original Message:
Sent: 7/22/2026 9:14:00 AM
From: Syndee Givre
Subject: RE: help with disc edema case

Right disc is crowded.  Left eye acuity and perimetry completely normal and she feels vision is normal other than during the TVOs.  Did not do color plates.  Lyme: 

This chemiluminescent assay detects IgM and IgG antibodies using a solid phase coated with Borrelia VlsE, variable major protein-like sequence, expressed antigens (B. burgdorferi and B. garinii) and Borrelia OspC, the outer surface protein (B. afzelii; crossreactive with B. burgdorferi).

Can Lyme cause disc edema without optic nerve dysfunction?

Thank you

Original Message:
Sent: 07-22-2026 09:20
From: Sherif Ahmed Kamel Abdelbar
Subject: help with disc edema case

I think if this is all normal it can be residual disc swelling from a previous insult or active swelling , a true swelling converting into pseudo swelling , follow monthly for example with visual fields , if the case is stable for 3 months then probably nothing active 

Sherif 

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Original Message:
Sent: 7/22/2026 9:14:00 AM
From: Syndee Givre
Subject: RE: help with disc edema case

Right disc is crowded.  Left eye acuity and perimetry completely normal and she feels vision is normal other than during the TVOs.  Did not do color plates.  Lyme: 

This chemiluminescent assay detects IgM and IgG antibodies using a solid phase coated with Borrelia VlsE, variable major protein-like sequence, expressed antigens (B. burgdorferi and B. garinii) and Borrelia OspC, the outer surface protein (B. afzelii; crossreactive with B. burgdorferi).

Can Lyme cause disc edema without optic nerve dysfunction?

Sure looks like a case of impending AION given the disk at risk on the right. The next question is what to do about it? I’ve used Ginkgo and Trental until the disk edema resolves, innocuous enough.

I’ve seen pseudopapilledema that looks VERY impressive, and normal ICP. I’ve also been surprised when routine pseudopapilledema patients show up on routine followup to have true papilledema on top of it. One wonders if they had elevated ICP all along that got worse, or they have two diagnoses.

Mitch


Original Message:
Sent: 7/22/2026 9:03:00 AM
From: Scott Forman
Subject: RE: help with disc edema case

Why would this be "impending" NAION. Is the other disk at risk? Color vision? field?

If the Lyme and other tic born dseases are "negative" is this by CDC Western blot which is only 25% positive? Does she have cognitive symptoms, arthralgias, etc ? How was Lyme treated in the past?

Scott Forman, MD

Original Message:
Sent: 7/22/2026 1:02:00 PM
From: Mitchell Gossman
Subject: RE: help with disc edema case

Sure looks like a case of impending AION given the disk at risk on the right. The next question is what to do about it? I’ve used Ginkgo and Trental until the disk edema resolves, innocuous enough.

I’ve seen pseudopapilledema that looks VERY impressive, and normal ICP. I’ve also been surprised when routine pseudopapilledema patients show up on routine followup to have true papilledema on top of it. One wonders if they had elevated ICP all along that got worse, or they have two diagnoses.

Mitch

Original Message:
Sent: 7/22/2026 3:34:00 PM
From: Larry Frohman
Subject: RE: help with disc edema case

Agree with this likely being impending NAION and getting an FA looking for a segmental nonperfusion

As an aside, a few months ago, I took care of a 65 year-old physician non-diabetic, but placed on Ozempic for a metabolic syndrome

She presented with ischemic optic neuropathy  with arcuate field defects in one eye and the other eye, swollen yet asymptomatic, including normal fields

Worried about second eye involvement, we stopped the Ozempic, which she had been on for a few months and I put her on a cocktail of brimonidine and Diamox to try to improve the perfusion gradient, as well as low-dose aspirin and Trental

The previous eye, after six months,  has been stable and is no longer swollen and the previouslyswollen asymptomatic eye defervesced without any visual loss

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Original Message:
Sent: 7/22/2026 1:02:00 PM
From: Mitchell Gossman
Subject: RE: help with disc edema case

Sure looks like a case of impending AION given the disk at risk on the right. The next question is what to do about it? I’ve used Ginkgo and Trental until the disk edema resolves, innocuous enough.

I’ve seen pseudopapilledema that looks VERY impressive, and normal ICP. I’ve also been surprised when routine pseudopapilledema patients show up on routine followup to have true papilledema on top of it. One wonders if they had elevated ICP all along that got worse, or they have two diagnoses.

Mitch

Original Message:
Sent: 7/22/2026 4:00:00 PM
From: Russell Edwards
Subject: RE: help with disc edema case

How was she evaluated for disc drusen? I am unaware of any single modality that rules them out.oc, ultrasound, fluorescein angiogram, autofluoresence, oral fluorescein. Prior examinations to name a few . Of course, odd do not protect from naion,so it's reasonable to take steps to reduce the likelihood of progression to ion. 

Consider lowering nocturnal IOP

 Avoid on dosing of antihypertensives in addition to the suggestion of trental.

Russ Edwards

Original Message:
Sent: 7/22/2026 3:34:00 PM
From: Larry Frohman
Subject: RE: help with disc edema case

Agree with this likely being impending NAION and getting an FA looking for a segmental nonperfusion

As an aside, a few months ago, I took care of a 65 year-old physician non-diabetic, but placed on Ozempic for a metabolic syndrome

She presented with ischemic optic neuropathy  with arcuate field defects in one eye and the other eye, swollen yet asymptomatic, including normal fields

Worried about second eye involvement, we stopped the Ozempic, which she had been on for a few months and I put her on a cocktail of brimonidine and Diamox to try to improve the perfusion gradient, as well as low-dose aspirin and Trental

The previous eye, after six months,  has been stable and is no longer swollen and the previouslyswollen asymptomatic eye defervesced without any visual loss

Sent from my iPhone

Original Message:
Sent: 7/22/2026 10:16:00 AM
From: Shikha TALWAR
Subject: RE: help with disc edema case

Asymmetric papilloedema/pseudopapilloedema cause TVO. Could you share the OCT and the MRI images ?

Regards

Dr Shikha Bassi

Sankara Nethralaya 

Chennai

India

Original Message:
Sent: 7/22/2026 10:16:00 AM
From: Shikha TALWAR
Subject: RE: help with disc edema case

Asymmetric papilloedema/pseudopapilloedema cause TVO. Could you share the OCT and the MRI images ?

Regards

Dr Shikha Bassi

Sankara Nethralaya 

Chennai

India

Original Message:
Sent: 7/22/2026 10:28:00 AM
From: Andrew Carey
Subject: RE: help with disc edema case

Definitely could be impending NAION.

I agree, definitely want to review the MRI images yourself and make sure they didn't miss an optic nerve sheath enhancement, an optic nerve sheath meningioma would be high on the differential.

Is there any vitreopapillary traction on the cross section OCT?

Other mimickers include peripapillary CNV, typically with peripapillary SRF; peripapillary capillary hemangioma (von hippel lesion).

Lyme can cause disc edema without optic nerve dysfunction in the setting of uveitic disc edema, as well as other forms of uveitis. A fluorescein angiogram might be helpful since retrobulbar etiologies have been ruled out.

Best, 

Drew

thanks everyone for your thoughts.  just re-reviewed MRI images.  Sella not empty and retrobulbar optic nerves are again normal on a good quality orbit scan.  Traction was one of my first thoughts but scrolling through the OCT scans there is no traction on the disc.  No vitreous, no AC cell.  I'll talk to her about FA. 

Original Message:
Sent: 07-22-2026 10:27
From: Andrew Carey
Subject: help with disc edema case

Definitely could be impending NAION.

I agree, definitely want to review the MRI images yourself and make sure they didn't miss an optic nerve sheath enhancement, an optic nerve sheath meningioma would be high on the differential.

Is there any vitreopapillary traction on the cross section OCT?

Other mimickers include peripapillary CNV, typically with peripapillary SRF; peripapillary capillary hemangioma (von hippel lesion).

Lyme can cause disc edema without optic nerve dysfunction in the setting of uveitic disc edema, as well as other forms of uveitis. A fluorescein angiogram might be helpful since retrobulbar etiologies have been ruled out.

Best, 

Drew

Original Message:
Sent: 7/22/2026 10:16:00 AM
From: Shikha TALWAR
Subject: RE: help with disc edema case

Asymmetric papilloedema/pseudopapilloedema cause TVO. Could you share the OCT and the MRI images ?

Regards

Dr Shikha Bassi

Sankara Nethralaya 

Chennai

India

Any chance she’s been on amiodarone for her atrial fibrillation, discontinued (perhaps in response to the disc edema) so it doesn’t show up on her medication list? vp


Original Message:
Sent: 7/22/2026 10:43:00 AM
From: Syndee Givre
Subject: RE: help with disc edema case

thanks everyone for your thoughts.  just re-reviewed MRI images.  Sella not empty and retrobulbar optic nerves are again normal on a good quality orbit scan.  Traction was one of my first thoughts but scrolling through the OCT scans there is no traction on the disc.  No vitreous, no AC cell.  I'll talk to her about FA. 

Original Message:
Sent: 07-22-2026 10:27
From: Andrew Carey
Subject: help with disc edema case

Definitely could be impending NAION.

I agree, definitely want to review the MRI images yourself and make sure they didn't miss an optic nerve sheath enhancement, an optic nerve sheath meningioma would be high on the differential.

Is there any vitreopapillary traction on the cross section OCT?

Other mimickers include peripapillary CNV, typically with peripapillary SRF; peripapillary capillary hemangioma (von hippel lesion).

Lyme can cause disc edema without optic nerve dysfunction in the setting of uveitic disc edema, as well as other forms of uveitis. A fluorescein angiogram might be helpful since retrobulbar etiologies have been ruled out.

Best, 

Drew

Agree.  The LP was done under fluoro by a neuro-rad I know personally so I tend to think it's accurate.  The second strike against papilledema is the normal right disc.  I know both the ICP and unilaterality can be misleading but to have both be misleading in the same patient would be even more unlikely.  What specifically on the MRI would be helpful?

Original Message:
Sent: 07-22-2026 10:15
From: Shikha TALWAR
Subject: help with disc edema case

Asymmetric papilloedema/pseudopapilloedema cause TVO. Could you share the OCT and the MRI images ?

Regards

Dr Shikha Bassi

Sankara Nethralaya 

Chennai

India

Original Message:
Sent: 7/22/2026 10:35:00 AM
From: Syndee Givre
Subject: RE: help with disc edema case

Agree.  The LP was done under fluoro by a neuro-rad I know personally so I tend to think it's accurate.  The second strike against papilledema is the normal right disc.  I know both the ICP and unilaterality can be misleading but to have both be misleading in the same patient would be even more unlikely.  What specifically on the MRI would be helpful?

Thanks for all the helpful suggestions and comments.  To follow up- called her- never took amiodarone and current med list is what she was taking for a while before the TVOs started.  I looked for drusen with OCT and B scan.  She is seeing her PCP and a sleep doc.  Sending her for FA and will talk to her about Trental.  

Original Message:
Sent: 07-22-2026 12:28
From: Floyd Warren
Subject: help with disc edema case

Your impending nAION is sounding like the best bet 

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