29-year-old woman presents with subacute vision loss and headaches

A 29-year-old obese white woman with a known history of idiopathic intracranial hypertension, or IIH, presented to the New England Eye Center with 1 month of progressively decreasing vision in her right eye and positional headaches. She was diagnosed with IIH 5 years prior, after presenting with transient visual obscurations in her right eye and headaches. She was noncompliant with oral medications and had a recent 45-pound weight gain.On examination, best corrected visual acuity was 20/200 in the right eye and 20/20 in the left eye. The patient had an afferent pupillary defect and color desaturation in the right eye. Humphrey visual field 30-2 testing revealed paracentral loss and an inferotemporal scotoma in the right eye; testing was normal in the left eye. Fundus examination was notable for bilateral optic disc edema and venous tortuosity. There was a superotemporal peripapillary subretinal hemorrhage with subretinal fluid and exudate in the right eye (Figure 1a), which was consistent with choroidal neovascularization on fluorescein angiography (Figure 1g). Spectral-domain OCT of the macula revealed a distorted foveal contour with intraretinal and subretinal fluid in the right eye (Figure 1d).