I. Case History
o 42 year old African American male
o No new complaints: presents for routine yearly follow up eye
examination
o Ocular history is significant for myopia, physiologic large C/Ds, and
white without pressure
o Medical history is remarkable for severe head trauma which
resulted in a coma, hx of craniotomy for subdural hematoma
II. Pertinent Findings
o Clinical examination
i. 20/20 OD, OS
ii. Pupils equally round and reactive with no RAPD
iii. CVF: Superior nasal defect OD, superior temporal and nasal
defect OS
iv. Inferior temporal ONH pallor OD, temporal ONH pallor OS
v. Optociliary shunt vessels OD
o Ancillary testing
i. Humphrey visual field: dense superior nasal defect and
inferior nasal edge defect OD, dense superior altitudinal
defect, inferior temporal edge defect, and inferior nasal-step
defect OS
o Brain imaging
i. CT scan and MRI of the head revealed brain atrophy in the
R temporal and occipital lobe
III. Differential Diagnosis of optociliary shunt vessels
o Papilledema
o Glaucoma
o Optic nerve sheath meningioma
o Optic nerve drusen
o Central retinal vein occlusion
IV. Papilledema
o Bilateral optic disc swelling caused by increased intracranial
pressure
o Occurs in 50 to 75% of patients with chronic subdural hematoma
o Post-papilledema optic atrophy at time of diagnosis
o Interesting finding of unilateral optociliary shunt vessels in a
bilateral optic nerve disease, similar findings in 7 case series by
Eggers and Sanders
V. Treatment
o Stable from an ocular standpoint, observe
o Social support for decreased function due to severe brain atrophy
VI. References
o Duke-Elder S, Scott GI. Neuro-opthalmology, vol 12. St. Louis, CV
Mosby, 1971, p. 39.
o Eggers HM, Sanders MD. Acquired optociliary shunt vessels in
papilloedema. Br J Ophthalmol 1980;64:267-71.
o Yamada SM, Teramoto A, et al. Severe papilledema identified 3
weeks after head trauma. Neurol Med Chir 2002;42:293-6.
o Saeed P, Rootman J, et al. Optic nerve sheath meningiomas.
Ophthalmology 2003;110(10)2019-2030.
VII. Conclusions
o Unilateral optociliary shunt vessels and bilateral optic atrophy
following severe head trauma
o Papilledema is common with chronic subdural hematoma
o Optociliary shunt vessels can develop unilaterally in papilledema