Thinking outside of the box

A 37-year-old man presented after developing horizontal double vision while driving, 10 days after surgery for metastatic oral cancer. He also reported a dull frontal headache and pulsatile tinnitus while lying flat for several days, preceding the double vision. The headache was worse in the mornings. He denied any visual blurring or obscurations. The double vision had persisted and was worse when he looked into the distance. Eighteen months previously he had been diagnosed with squamous carcinoma of the tongue and had undergone local surgical excision. Recently, metastatic spread to a left cervical lymph node was confirmed. CT scanning did not show any local recurrence. Subsequent radical neck dissection did not demonstrate further spread to other lymph nodes. There was no other significant medical history and he was taking codydramol and diclofenac for the combination of postoperative wound discomfort and headache. There had been no other recent drug use. He was a smoker. He originated from Pakistan and had lived in the UK for 13 years with his wife and son, who were well. This patient's general practitioner referred him urgently to ophthalmology. Examination demonstrated a thin man with normal visual acuity and colour vision (as tested with Ishihara plates). Abduction of the left eye was impaired but other eye movements were full. Ophthalmoscopy revealed moderately severe bilateral optic disc swelling with disc haemorrhages and marked peripapillary oedema (figure 1). Goldmann visual fields displayed minimal enlargement of blind spots bilaterally. Figure 1 Funduscopy showing bilateral optic disc swelling with haemorrhages. ### Question 1 Summarise the findings and consider which further investigations you would request The nature of this man's headache suggests raised intracranial pressure. The binocular, horizontal diplopia, worse when viewing …