A 44-year-old woman from Guyana was referred to the neurology services with headache and blurred vision. The ophthalmology services had made the referral following discovery of apparent bilateral papilloedema and a right retinal haemorrhage. A CT venogram reported enlarged optic nerve sheaths, empty sella and asymmetrical lateral sinuses. The initial lumbar puncture revealed a normal opening pressure of 14 cm H2O and clinical headache assessment suggested migraine. Further ophthalmology advice was sourobight. Having excluded drusen by B-scan ultrasound, a second lumbar puncture was performed and revealed opening pressure 23 cm H2O. Despite extensive investigation, diagnostic uncertainty persisted until the patient presented to Eye Casualty with acute deterioration in right eye visual acuity. A large retinal haemorrhage was noted and fluorescein angiography revealed multiple choroidal vascular polyps. A diagnosis of peripapillary polypoidal choroidal vasculopathy (PCV) was made. Treatment with intraocular anti-VEGF injections and photodynamic therapy successfully avoided permanent visual loss. Caution is advised when interpreting CT findings consistent with idiopathic intracranial hypertension, as PCV is an important differential diagnosis in unexplained papilloedema, which if left untreated can lead to irreversible blindness.
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