A 55-year-old woman complains of headaches that are made worse by coughing. They are increasing in frequency. She notices occasionally losing vision but only for a few seconds at a time. Her visual acuities are normal. During ophthalmoscopy, you notice that the optic disc margins in each eye are blurred and you have to refocus to see them clearly. What is going on?

The most important findings here are headaches worse on coughing, occasional vision loss and blurred bilateral optic disc margins. The blurred optic disc margins strongly suggest swollen optic discs (papilloedema). The optic discs are swollen and are above the plane of the retina, this is why they are blurred when the retina is in focus. This is why the ophthalmoscope needs to be refocussed in order to see the margins clearly. This is a serious eye sign and if left untreated will permanent and catastrophic vision loss.

Papilledema occurs when there is a build-up of pressure in or around the brain. Medical conditions that can cause increased pressure to develop include:

• Head trauma
• Inflammation of the brain or surrounding tissue
• Very high blood pressure
• Infection in the brain
• Brain tumour
• Bleeding in the brain
• Blockages of blood or cerebrospinal fluid in the brain
• Abnormalities of the skull

Idiopathic intracranial hypertension is a rare condition where too much cerebrospinal fluid is produced. Symptoms usually include headaches, visual disturbances, and ringing in the ears. The exact cause of this condition is unknown and is not related to any brain disease or injury. It often affects younger, obese females. It can also be associated with medications, certain antibiotics, thyroid hormone treatment, and corticosteroids.

It is critical to identify the cause of the papilloedema in this patient as the underlying conditions listed above can be life-threatening. The patient deserves to be referred to a medical practitioner on an urgent (within one-week) basis.