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Five things every eye MD needs to know about pseudotumor cerebri�Andrew G. Lee, MD� Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Clinical Professor, UTMB Galveston; UT MD Anderson Cancer Center; Adjunct Professor, Baylor COM, U.Iowa and U. Buffalo, SUNY

I have no financial interest in the contents of this talk

It’s called pseudotumor but it is a real disease that blinds people

Five things to know about pseudotumor cerebri� Size does not matter in NeuroOp� Obesity epidemic is here� Fulminant IIH is an emergency� Diamox and weight loss work� Sheath fenestration vs. CSF shunt

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1978: I wanted to be a doctor…2nd choice Jedi knight Size doesn’t matter

Little edema Little edema can be Big problem

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Obesity Trends* Among U.S. AdultsBRFSS, 1985(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1986(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1987(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”

person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1988(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

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Obesity Trends* Among U.S. AdultsBRFSS, 1989(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1990(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1991(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1992(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

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Obesity Trends* Among U.S. AdultsBRFSS, 1993(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1994(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1995(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1996(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

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Obesity Trends* Among U.S. AdultsBRFSS, 1997(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1998(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1999(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 2000(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

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Obesity Trends* Among U.S. AdultsBRFSS, 2001(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. AdultsBRFSS, 2002

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2003(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2004(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

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Obesity Trends* Among U.S. AdultsBRFSS, 2005(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2006(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2007(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2008(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2008

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2008

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Only in America

Grades of evidence Grades translated to real world1. Must do (standard of care, highly recommended practice)

2. Should do (show just cause why not following recommendation)

3. Could do (practice option)4. Voo doo (“so new it might not be true”)

5. Doo doo (unsupported, might be false, evidence to suggest potentially harmful)

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Acetazolamide (+ diet) better than Placebo (+diet)

Frisen grades of papilledema

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Placebo

Acetazolamide

Stenting of TSS in IIH

Pressure gradient across stenosis Chicken and the Egg

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Collapsible sinus Rigid sinus (stented)

Stent for IIH with stenosis

IIH with severe acute visual loss: lumbar drain + surgery

Weight loss + Diamox

Get ready for cold steel

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More shunts for IIH (1998-2002)

Rising annual aggregate caseload of new CSF shunts for IIH increased 350%during this 14-year interval, or 9.4% annually (P < 0.001).

Curry et al. Neurosurgery 2005;57:97-108 ONSF in US hospitals1988 to 2002 Curry et al. Neurosurgery 2005;57:97-108

Rise in bariatric surgery

Curry et al. Neurosurgery 2005;57:97-108

Patient outcome: Cost &0.5% mortality!

Curry et al. Neurosurgery 2005;57:97-108

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Five things to know about pseudotumor cerebri� Size does not matter� Obesity epidemic� Fulminant IIH� Diamox and weight loss work� Sheath fenestration vs. CSF shunt

What behavior changes do I want for you to make…. not just for your patients but for your kids, grandkids, yourself??

Drag yourself & your kid away from the computer!

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1978: I wanted to be a doctor…2nd choice Jedi knight

It turns out I got to be both

Thanks for your time & attention� Andrew G. Lee, MD� Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Adjunct Professor: Baylor College of Medicine, U. Iowa & Clinical Professor, UTMB Galveston, UT MD Anderson Cancer Center, U. Buffalo, SUNY