2026 Poster Presentations
P186: MULTIMODAL MANAGEMENT OF SEVERE PAPILLEDEMA FOLLOWING OTOGENIC CVST IN A CHILD: A RARE CAUSE OF IRREVERSIBLE OPTIC NEUROPATHY
Trisha Miglani, MD; Floyd Warren, MD; NYU Langone Health Department of Ophthalmology
A 12-year-old boy presented to the emergency department with three weeks of bilateral visual disturbances, including partial visual field blackouts and a central scotoma in the left eye. Pertinent medical history includes recent eight-day hospitalization for group-A streptococcus bacteremia and left-sided pseudomonas otomastoiditis complicated by thrombophlebitis of the left transverse/sigmoid sinus and internal jugular (IJ) vein. He underwent mastoidectomy, myringotomy, and treatment with IV antibiotics and anticoagulation. He was seen by an outside optometrist two months after discharge and referred to the emergency department for bilateral optic disc edema.
On examination, visual acuity was 20/200 PH 20/30 and 20/400 PH 20/50, with decreased color vision and a left abduction deficit. Fundus exam revealed severe bilateral disc edema with hemorrhages, vessel obscurations, peripapillary exudates and a serous retinal detachment in the left eye (Figure 1). Work-up was consistent with elevated intracranial pressure (ICP). Lumbar puncture (LP) opening pressure was >55 cm H2O and MRI demonstrated thickening of optic nerve sheath complexes. MRV confirmed persistent thrombosis of the left transverse/sigmoid dural venous sinuses and proximal IJ (Figure 2).
The patient was treated with acetazolamide and steroids but had progression after about two weeks, requiring repeat LP and venous sinus angioplasty. A few months later, patient reported worsening vision, and repeat angiogram demonstrated persistently elevated venous sinus pressure in the 30s. He underwent placement of a ventriculoperitoneal (VP) shunt and symptoms improved. He continues to follow closely with neuro-ophthalmology, neurosurgery and otolaryngology. Despite aggressive interventions, he has residual optic nerve atrophy secondary to severe disc edema but remains stable on acetazolamide therapy.
This case is notable for its severe optic nerve and retinal findings, and it highlights a vision-threatening complication of pediatric cerebral venous sinus thrombosis (CVST). The patient developed severe bilateral papilledema and vision loss following otomastoiditis, complicated by left transverse/sigmoid sinus thrombosis, a rare but serious complication of mastoiditis. As Castellazzi et al. note, cases often present subtly with infection masking early signs, making timely diagnosis critical.¹
Despite appropriate antimicrobial, surgical, and anticoagulation therapy, the patient’s persistent thrombosis led to sustained intracranial hypertension. According to Sun et al., papilledema occurs in nearly 90% of pediatric CVST cases, with over half experiencing permanent optic nerve damage, particularly those with Frisén grades ≥3.2 This patient’s progressive visual decline despite initial therapy highlights the need for early and aggressive ICP control. Although endovascular angioplasty was attempted, it did not provide lasting improvement, consistent with findings by Rahm et al., who report that angioplasty alone is often insufficient and may require subsequent CSF-diversion procedures.³ Ultimately, a VP shunt was necessary.
Anticoagulation remains a mainstay in CVST treatment. However, as Shlobin et al. emphasize, treatment protocols remain undefined, and care must be individualized.4 This case reinforces the need for multidisciplinary coordination and early neuro-ophthalmologic evaluation to minimize long-term morbidity.
1. Castellazzi L, et al. Ital J Pediatr. 2020.
2. Sun A, et al. Am J Ophthalmol. 2024.
3. Rahm SM, et al. Pediatr Neurosurg. 2025.
4. Shlobin NA, et al. Pediatr Neurol. 2020.