NANOSNET

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

Hi Deb.  How do you fit elevated ICP and the presence of venous pulsations into your patient's story?  Symptoms and signs?  Some kind of artifact?  I usually am happy when a measure of ICP is reassuring and not if otherwise, like with this lone elevated closing pressure.

Steven

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

Hi Stephen,

Fair enough.  20/25+ OU, AOHRR 5/6 OU, normal pupil reactivities, attached fields not striking to my eyes.  ARNFL 144 OU.  The difference in colors between discs is photographic, not physiologic, at least for my direct ophthalmoscope.  The question of arteriolar narrowing is not supported by direct visualization.  They really look similar.  The question of enhancement of posterior sclera OU is unanswered.  I believe the LP was done with sedation according to mom.  I wondered if sedation could have been waning as the closing pressure was measured, producing Valsava artifact.  Curious if the group feels that OCT is more reliable or sensitive than sonography for detecting buried drusen.  I've tended toward the latter for my patients who are nearly all children.

Steven

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

Hi Stephen,

Fair enough.  20/25+ OU, AOHRR 5/6 OU, normal pupil reactivities, attached fields not striking to my eyes.  ARNFL 144 OU.  The difference in colors between discs is photographic, not physiologic, at least for my direct ophthalmoscope.  The question of arteriolar narrowing is not supported by direct visualization.  They really look similar.  The question of enhancement of posterior sclera OU is unanswered.  I believe the LP was done with sedation according to mom.  I wondered if sedation could have been waning as the closing pressure was measured, producing Valsava artifact.  Curious if the group feels that OCT is more reliable or sensitive than sonography for detecting buried drusen.  I've tended toward the latter for my patients who are nearly all children.

Steven

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

Hi Stephen,

Fair enough.  20/25+ OU, AOHRR 5/6 OU, normal pupil reactivities, attached fields not striking to my eyes.  ARNFL 144 OU.  The difference in colors between discs is photographic, not physiologic, at least for my direct ophthalmoscope.  The question of arteriolar narrowing is not supported by direct visualization.  They really look similar.  The question of enhancement of posterior sclera OU is unanswered.  I believe the LP was done with sedation according to mom.  I wondered if sedation could have been waning as the closing pressure was measured, producing Valsava artifact.  Curious if the group feels that OCT is more reliable or sensitive than sonography for detecting buried drusen.  I've tended toward the latter for my patients who are nearly all children.

Steven

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

If it was my child, I would opt for observation is there is no afferent dysfunction :) The discs don't look too concerning especially for a young child. 

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane

I've seen a thin 11 years old girl with elevated optic discs a few times during the past 3 months.  Her optic disc appearances are unchanged from their appearances in the attached photos from November.  Elevated optic disc appearances were first noticed during optometric examination 8 months ago while she was being evaluated for a very wide range of symptoms that began more than 1.5 years ago.  Symptoms seem overall mild as judged by the absence of behavioral changes and include aches and pains involving pretty much every part of her body, joint popping, migrator muscle pains, chills, a bad taste in her mouth (before treatment with Diamox was given), GERD, perioral blisters, fatigue, and more.  MRI/MRV c and s marred by motion artifact did not show a significant lesion or any classic signs of PTCS.  The only sign to consider is some enhancement of posterior sclera on each side is difficult to understand in the absence of signs or symptoms of scleritis/uveitis.  Buried drusen were found with sonography on each side.

The unsettling caveat is from the LP that was done when she presented to an ER before we met.  An opening pressure was (attempted?) but not recorded.  CSF composition including titers for many infectious processes (treponemes, viruses) was normal aside from an increased number of RBCs.  In spite of my inquiries, an explanation for the absent OP was not offered.  While an opening pressure was not recorded, a closing pressure was recorded and here's the rub: 35 cm water.  What to make out of this isolated closing pressure?

Would you just repeat the LP?  Or just follow her?  I saw her yesterday and observed a happy kid with otherwise normal findings.

Thanks,

Steven Kane