The contribution of macular changes to visual loss in benign intracranial hypertension

Purpose To describe the significance of macular changes to visual outcome in benign intracranial hypertension (BIH). Method The clinical and photographic records of 24 patients with BIH who required optic nerve sheath fenestration were analysed. Results Macular changes were found in 21 of 48 (44%) eyes. These were: choroidal folds 9; circumferential lines (Paton's lines) 4; nerve fibre layer haemorrhage 3; macular stars 5; macular oedema 6; retinal pigment epithelial changes 4; subretinal haemorrhage leading to a macular scar 1. Significant visual loss attributable to the macular changes was found in 5 eyes in the short term and 3 in the long term. The 2 eyes that improved had macular stars. Of the 3 eyes that did not improve, 2 eyes had retinal pigment epithelial changes and 1 a large subretinal haemorrhage that led to a macular scar. These 3 cases had long-standing BIH. Conclusions The majority of macular changes resolve and do not add to visual loss from optic nerve damage. Patients with marked macular oedema are at most risk of permanent visual loss and should be considered for early treatment such as optic nerve sheath fenestration.