My 13-year-old patient has presented for a routine eye examination. He says he can see perfectly well without his glasses. His refraction has changed from -1.00 DS in each eye to plano in each eye. He has 6/5 in each eye without any refractive correction. Both his optic discs have unclear nasal margins, normal temporal disc margins, a greyish halo with a temporal gap and concentric choroidal floods. He denies any headaches and any other visual problems. There is also spontaneous venous pulsation and no visual field defect.

This sounds odd and worrying. The hyperopic shift from -1.00 DS to plano is very suspicious. The causes of this type of hyperopic shift are never good. The greyish halo and concentric choroidal folds are highly suggestive of very early papilloedema and this can be caused by raised intracranial pressure (ICP).

is typical with raised ICP but this does not occur in all cases. A hyperopic shift may occur due to axial length shortening. Increased intracranial pressure leads to increased cerebrospinal fluid (CSF) within the dilated optic nerve sheath and flattening the back of the eye.

As spontaneous venous pulsations are present, this suggests that ICP is probably not high at this time, however, the ICP may have been high before due to diurnal variations in ICP. This patient needs urgent referral (within one week) to an ophthalmologist, or a neuro-ophthalmologist, or a neurologist for further investigation. His sight and his life are in danger.

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