An 18-year-old hispanic female presented for a recheck of her recently fulfilled glasses. Her chief complaint was headaches that started 2-3 months ago. The patient received her glasses 2-3 weeks prior. She described the headaches as worsening for the last 2 months, daily and dull without tinnitus. The patient discontinued her birth control medication as she was suspecting it to be causing the headache. As the headaches persisted, she was seen by her pediatrician who suspected sinusitis and prescribed antibiotics, without improvement. The patient then came back to us to double check her glasses prescription.

She reported being healthy and had no relevant medical history.

On examination, pupils were round and reactive without APD, EOM were full, she was full to finger count OU. The patient had low myopia and recheck of her refraction was only 0.25 more minus compared to her current glasses which did not justify the chief complaint. Her visual acuity was 20/20 in both eyes.

Anterior segment and IOP were WNL.

The patient asked, “can we please repeat the photo of the back of the eye like the one we did 3 months ago?” I found it really odd that the patient was aware that her symptoms could potentially be linked to her fundus. We repeated the fundus photo. See below.

Fundus photos and OCT at first presentation in October 2023:

Fundus photos and OCT at follow up in January 2024:

Fundus evaluation showed swelling of the both optic nerves. OCT highlights significant thickening of the peripapillary NFL OU.

Swelling of both optic nerves along with headaches, raised a significant concern about a potential ongoing intracranial condition. The patient was immediately sent to a nearby urgent care for initial imaging of the head with a CT scan. After performing the test, the urgent care referred the patient to the hospital for a brain MRI STAT. See below (this is an image of a different patient with a similar presentation).

Radiology report was as follows: Cystic mass seen in the right cerebellum measuring 5.3 x 4.5 cm in size with surrounding vasogenic edema and adjacent CSE extra-axial cyst. The lesion is most compatible with a pilocytic astrocytoma.

Discussion:

Pilocytic astrocytomas are the most common benign brain tumors of children and young adults, and account for approximately 5% of all gliomas. They arise from astrocytes, which are part of the supporting tissue (glial cells) of the central nervous system and are therefore classified as gliomas. Microscopically, pilocytic astrocytomas have a fibrous “pilocytic” character. Macroscopically, they are often cystic, meaning that pilocytic astrocytomas consist of a mixture of fluid-filled cavities and solid portions. Most pilocytic astrocytomas are slow-growing tumors that do not spread to other parts of the body and have a very good prognosis.

In children, pilocytic astrocytomas arise frequently from the astrocyte cells of the cerebellum, a region that plays a crucial role in movement and balance. However, pilocytic astrocytomas can also arise in the visual pathway, cerebrum, or brainstem.

If possible, the first choice treatment is the complete microsurgical removal of the pilocytic astrocytoma. Especially in juveniles, a cure can be achieved after complete removal of the tumor in most cases with a 10-year survival rate of up to 100% and a recurrence rate of only 2–5%. After complete tumor removal, neither radiation nor chemotherapy is necessary. If a residual pilocytic astrocytoma remains after surgery and cannot be surgically removed, radiotherapy is an effective option.

Our patient will undergo surgical removal of the lesion and as stated above, her prognosis is excellent.

This case highlights the importance of Optometry in society today.

I hope you enjoyed this case and I’ll see you next month!

Many thanks to Dr. Leoncio Gonzalez for sharing this case with me.