May 15, 2025 • 33 mins
In this episode of The Eye-Q Podcast™, Dr. Rani Banik and Dr. Valerie Elmalem, MD discussed idiopathic intracranial hypertension (IIH), a condition characterized by elevated pressure in the cerebrospinal fluid. They explore the symptoms, diagnostic methods, and treatment options for IIH, emphasizing the importance of weight management and lifestyle changes. The conversation provides valuable insights into the complexities of IIH and its impact on vision and overall health.
IN THIS EPISODE YOU WILL LEARN
00:00 – What is IIH, and what symptoms should you watch for?
04:30 – What exactly is Idiopathic Intracranial Hypertension (IIH)?
09:30 – How can IIH be differentiated from other conditions?
13:00 – What types of headaches are common in IIH?
15:38 – What diagnostic tests are used to confirm IIH?
19:41 – What treatment options are available for IIH?
26:55 – How do weight management and lifestyle changes help with IIH?
Connect with Valerie Elmalem, MD
Website: https://profiles.mountsinai.org/valerie-i-elmalem
Free eBooks
What is Idiopathic Intracranial Hypertension (IIH)?
6 Natural Ways to Conquer Headaches
Product Links
SHOP Ageless by Dr. Rani: https://shop.rudranibanikmd.com/
Dr. Rani’s Instagram: https://www.instagram.com/dr.ranibanik/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Let me ask you this, have you ever experienced headaches that
are pressure like like a band sensation around your head along
with blurry vision, particularlyif you sit up too quickly or you
bend down to pick up something and come back up?
If your vision goes blurry with a pulsating sound in your ears,
like almost like water or a swishing sound like with your
(00:22):
heartbeat. Well, if you've had any of these
symptoms, you may, and I say may, you may have a condition
known as idiopathic intracranialhypertension, also known as IIH
for short. Well, to learn more about IIH,
I've invited one of my colleagues who's a leading
neuroophthalmologist, Dr. Valerie Elmolim, to join us on
(00:44):
the IQ Podcast. So stay tuned if you want to
learn more about IIH. Welcome to the IQ podcast,
hosted by Doctor Ronnie Bannock,America's integrative neuro
ophthalmologist. Get ready to explore the
intricate connections between the brain and the eye through
neuro ophthalmology. Journey with Doctor Ronnie into
(01:06):
the world of integrative ophthalmology, where cutting
edge science meets holistic Wellness.
Discover how to protect and preserve vision through powerful
preventative strategies based onice, smart nutrition, and
lifestyle modifications. Whether you're an eye care
provider or just curious about to maintain healthy vision so
you can see the world more clearly, join Doctor Ronnie for
(01:26):
exciting and eye opening discussions which will no doubt
raise your IQ. Welcome everyone to another
episode of the IQ Podcast. I'm your host, Doctor Ronnie
Vanik, and through this podcast,you'll learn insights about
vision health and brain health to help you raise your IQ.
Today I'm so excited to introduce our guest for this
(01:48):
episode, Doctor Valerie Elmalam.Thank you.
Thanks for having me. Welcome, Doctor El Mullim.
So Doctor El Mullim is an associate professor of
ophthalmology and director of neuro Ophthalmology at New York
Ioneer of Mount Sinai Hospital System.
She's very involved with teaching medical students and
residents as well as educating her peers at national meetings.
(02:11):
So we are so honored to have youwith us today.
And I always like to start off by asking our guest, Doctor El
Mullim, what was it that inspired you to go into your
field? So was there like a particular
moment or patient that you'd seen that made you want to
pursue neuro ophthalmology as a subspecialty?
So I always loved neuroscience, even growing up.
(02:35):
I was always a fan of science ingeneral since I was very little.
I think maybe around 4 years oldis when my parents started told
me that I became interested in medicine in general.
I don't know that there was necessarily any specific events
that made me interested, but initially I wanted to pursue
(02:58):
neurosurgery because I liked anatomy and I really liked
neuroscience. And then there was actually a
surgeon in medical school who told me to look into
ophthalmology and told me that there was a lot of neuroscience
involved in ophthalmology and a little bit of an easier
(03:20):
lifestyle. Absolutely.
So when I did my rotation in ophthalmology as a medical
student, everybody was so happy with their field and the
patients were very grateful for being able to have the gift of
sight. So I still wanted to integrate
(03:44):
my interest in neuroscience and became interested in pursuing
neuro ophthalmology. Well, that's wonderful and I'm
so glad you decided to pursue ophthalmology and neuro
ophthalmology rather than neurosurgery.
It's wonderful to have you as a colleague, you know, Doctor Elmo
Lemon actually, and I actually work side by side at our
hospital. So it's, it's really a pleasure.
(04:05):
So Doctor Elmo for today's episode on the IQ podcast, we're
we're focusing on this conditionknown as idiopathic intracranial
hypertension. It's a mouth mouthful, but we
call it IIH for short. Can you give our listeners a
general overview of what is thiscondition IIH?
And then we'll go into some moreof the details, but just give us
(04:26):
first like an overview, like a 30,000 foot view of what this
is. So, idiopathic intracranial
hypertension is a neurologic condition where you have
elevated pressure in the cerebral spinal fluid.
So elevated intracranial pressure and this pressure gets
transmitted to your optic nerves, which are the nerves
(04:49):
that connect the eye to the brain.
And when the pressure is high, it causes swelling of your optic
nerves and this can threaten vision.
This condition is common in younger women in their 20s,
thirties and 40s who are overweight and we don't know the
(05:11):
exact reason why we have an association with being
overweight, but we know that with weight loss this condition
often improves and even goes away.
And some of the treatments are targeted towards lowering the
pressure in the cerebral spinal fluid so we can relieve the
(05:32):
pressure on the optic nerves. Well, thank you for that.
That was so enlightening. So you mentioned that this
condition is associated with high pressure in the brain.
Now there are other conditions also that may cause similar
symptoms or high pressure in thebrain as well.
So how do you distinguish between IIH versus some of those
(05:53):
other conditions that may potentially be not just vision
threatening, but even life threatening?
How can you tell the difference?Right.
So as part of the evaluation in someone who has swelling of the
optic nerves, we want to see if they have any other conditions
other than idiopathic intracranial hypertension.
(06:14):
And that could include a tumor like a brain tumor that could be
increasing the pressure or even causing direct pressure on the
optic nerves. It could be a blood clot in the
veins that drain the fluid from,you know, those cerebral spinal
(06:34):
fluid and that can cause a backup and a build up of
pressure. So we, we look for those
conditions by doing an MRI of the brain with contrast so that
we can see if there's a tumor there.
And we also do an MRV or an Mr. venogram where we look at the
(06:55):
blood vessels, the veins that drain the fluid from the the
cerebral spinal fluid and we cantell if there is a tumor or a
blood clot that would be causingthe increase and the pressure
and you won't see those things. That's when we think about
idiopathic intracranial hypertension.
(07:18):
So basically you're saying, Doctor Elmalam, that the patient
has to undergo these specific tests before we can call this
idiopathic. By the way, for our listeners,
idiopathic means we don't reallyknow what causes it.
So there's an unknown there. There's no specific 'cause I
wanted to ask you a little bit about, you know, IIH has been
known by many different terms inthe past.
(07:40):
And one of the terms we commonlyused to use for this was pseudo
tumor cerebri. So can you tell us a little bit
about pseudo tumor cerebri, whatit, what that entity is and
whether, you know, we still use that term sometimes or how is it
different than IIH or maybe there's overlap?
Can you shed some light on that?Yeah, there there are people
(08:01):
that still refer to it interchangeably with pseudo
tumor, cerebri and idiopathic intracranial hypertension.
But the term pseudo tumor is problematic because it is the,
the term pseudo is basically saying like, so it's they're
saying that it's behaving like if you have a brain tumor.
(08:24):
And I think that term can be a little bit scary for patients.
And you know, it doesn't necessarily refer to all of the
underlying conditions that that can cause swelling of the optic
nerves. So there are still people that
refer to it as pseudo tumor cerebri, but I think the more
(08:44):
accepted term is idiopathic intracranial hypertension.
The other term that it used to be called is benign
entrepreneurial attention, and we definitely do not use that
term anymore because it's not always a benign condition
because you can lose vision fromit.
Yeah, I think that's so important for people to realize
(09:07):
and, and hopefully that term benign has really fallen out of
favor. I know that there's still some
perhaps older practicing doctorswho still use that term, but it
certainly is not benign because it can cause not just vision
issues, but other neurologic symptoms as well.
Let's talk about just specifically.
So now we're just talking about idiopathic endocrinial
(09:28):
hypertension. You mentioned some of the risk
factors. What are some of the symptoms
that can happen that patients may experience with this
condition? Yeah.
The most common symptom is headache, which occurs in over
80% of patients who have idiopathic intracranial
hypertension. And the specific type of
(09:49):
headache that you get is worse when you wake up in the morning.
And the reason for this is because you've been laying down
all night, so the pressure in your head is a little bit higher
when you're first waking up. So sometimes this headache can
even wake them up not from sleeping.
It's usually a pounding or throbbing headache.
(10:12):
Some people will complain of pressure behind the eyes.
And then the other common symptom you can have is a
swishing noise in your ears, which can occur around the same
time as your heartbeat. So we call it pulsatile tinnitus
or pulp ankle tinnitus. So I started to interrupt, but
(10:36):
not like a high pitched ringing in the ear.
This is a different type of sound, correct?
Because a lot of people have a high pitched ringing in the
ears. It's very common.
Right, exactly. And I'll, I'll usually ask
people if they hear sort of likethe sound of the ocean, you
know, it's more of a swishing than the high pitched ringing or
buzzing that you may get with tinnitus that can be associated
(11:00):
with ear problems. Another symptoms that you can
have is more common in people who have more swelling of the
optic nerves, which is called transient visual obscurations.
What this is is when you change position.
So if you stand up quickly or ifyou come to a sitting position
(11:22):
from laying down, sometimes you can get a temporary blackout or
white out of the vision that lasts just a couple seconds and
then comes back. Some people will describe seeing
spots in their vision instead ofthis black out or white out of
vision, but they're temporary changes in the vision that occur
(11:43):
due to swelling of the optic nerve, and this is because of
the pressure on the blood vessels supplying the eye from
all that swelling. Yeah, this last week actually, I
saw a patient with newly diagnosed IIH and she described
she would have these transient blackouts whenever she bent down
to either like tie her shoe or pick something up off the floor.
(12:05):
She would bend down for just a few seconds, get back up, and
everything would just be Gray and pixelated.
And then her vision would come back into into focus.
So again, positional changes arereally key there.
Some other symptoms that people can have, they can have
dizziness, they can have neck stiffness when the pressure is
(12:26):
really high and and rarely but it can occur.
You can have some some changes in concentration or cognitive
changes that occur with the highpressure.
Absolutely. Now I wanted to talk a little
bit more about the headache because many people get
headaches of all kinds, whether it be tension headache or
(12:47):
migraine headache. How can one differentiate
headache that's from high pressure in the brain that may
be from IIH versus a migraine? Are there specific symptoms that
they should be watching out for?Yeah.
So as I mentioned before, the headache that is associated with
the high pressure very commonly can occur when you're laying
(13:09):
down or right when you're wakingup in the morning.
So if your headache is worse right when you wake up and then
it goes away after about an houror two when you've been standing
for a while, that can be a symptom to look out for.
And sometimes people have worsening headache when they're
changing position, like if they're bending down, as you
(13:32):
mentioned, when with your patient who had the change in
vision with bending, the headache can also get worse with
changes in position. So my, this is as opposed to
migraine where it can occur at any time of the day.
And you, some people will get a warning sign that they're
getting a migraine, like some zigzags or changes in their
(13:55):
vision, or they'll get pain, youknow, behind one eye and then
it'll spread to the other side. And they usually will get better
with certain types of medication, but can be
associated with nausea, light sensitivity, activity, and sound
sensitivity. So there can be some overlap
(14:16):
with migraines. So many people who get
idiopathic intracranial hypertension, you know, are
young women and young women alsocommonly have migraines.
So there certainly can be overlap, but the the
differentiating feature is the headache will get worse with
changing position. And I think have that, then
(14:39):
that's something to really look into.
Yeah, those are some great tips,Doctor Elmolim.
I've actually had a lot of patients who have had a previous
diagnosis of migraine for many years, or perhaps, you know, a
new diagnosis of migraine, then they slowly notice that there
are headache changes in its characteristics and they
ultimately get diagnosed with IIH.
(14:59):
So it is possible to have two together, both of the conditions
together. But many patients can
differentiate the type of headache that they're getting
like, oh, this is my pressure headache versus this is my
migraine headache. So you just really have to pay
attention to your symptoms and maybe, you know, keep a log, jot
them down and try to identify the pattern that's happening.
(15:20):
That may help you identify the cause.
So Doctor Elmo, you talked earlier about a couple of tests
that need to be done to diagnosethis condition.
IIH from a, so you mentioned like for example, MRI, you
mentioned Spinal Tap. What about vision tests?
Like from a neuro ophthalmologist perspective,
which vision tests do you rely on the most to help monitor
(15:42):
these patients and and and watchtheir vision?
Yeah. So we will check the vision on
the eye chart, the visual acuity.
We will do a peripheral vision test called a visual field,
where we test not just the center but also the peripheral
(16:03):
vision because commonly in idiopathic intracranial
hypertension, the first vision to be affected is actually the
peripheral vision, not the center vision.
So many times people won't even know, they won't even be aware
that they have peripheral visionloss until it gets closer to the
(16:23):
center and then you know, it's, it's later on in their, in their
course and we really want to catch it early.
The other test we look for is color vision because in optic
nerve conditions you can have decreased color vision when it's
a little bit more advanced. And we also do some pictures of
(16:45):
the optic nerve. One of the pictures that we rely
on mostly to tell if things are getting better or worse is the
Oct test, which is optical coherence tomography.
This is a picture where we can actually measure the thickness
and look at the configuration ofthe optic nerve to tell if there
(17:09):
is worsening or improving swelling.
And. By the configuration of the
optic nerve on this test, we canalso tell if there is high
pressure like the cerebral spinal fluid that's kind of
pushing on the optic nerve to change its configuration, you
(17:29):
know, moving up rather than the normal configuration which is
down. So we really rely on this test
heavily for following, for firstdiagnosing and also for
following patients with idiopathic intracranial
hypertension. Well, thank you for sharing
those. So again, just to recap what
Doctor Elmalim said, we check vision, we check color vision,
(17:54):
We also check pupils and we checked the field, which is
very, very important. And perhaps the most important
test that we do is we monitor the peripheral vision and then
we do imaging of the optic nervesuch as an Oct test and
sometimes even photographs of the optic nerve to document how
much swelling there is. You've been.
Listening to the IQ Podcast withme, Doctor Ronnie Banik.
(18:16):
We're going to take a short break and then we'll be right
back with more insights to help you raise your IQ.
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(19:19):
your migraine naturally. Welcome back everyone to the IQ
Podcast. Today we're chatting with Doctor
Valerie Elmalem, a leading neuroophthalmologist and expert in
IIH. So Doctor Elman, we've talked
about what may be risk factors for IIH, what it is, what the
symptoms are, what the findings are on eye exams.
(19:41):
Now let's talk about treatment because I know that's what
people want to know about, you know, how can I take care of
this? Can it make, can I make it go
away? What can be done?
So when you first see a patient,what are some options that you
consider for treatment for IH? The the treatment options that I
discussed with patients really depends on their vision and also
(20:04):
the amount of swelling of their optic nerves.
So we have a grading system for the amount of swelling of the
optic nerves. And just, you know, to give you
an overview, you can have mild, moderate or severe swelling.
And in the more mild category where people do not have any
(20:25):
changes in their peripheral vision and they have normal
vision and relatively mild symptoms.
Sometimes I will consider just advising a low salt diet and
weight loss to as treatment. And then I follow them closely
to see if they're getting better.
The next step up would be to addon a medication called
(20:49):
acetazolamide, which is a water pill, a diuretic that decreases
the production of the cerebral spinal fluid to decrease the
pressure. And that we still also recommend
the diet and the weight loss, the low salt diet and weight
loss in addition to using the acetazolamide.
(21:10):
And we can start with a lower dose of 500 milligrams twice a
day and then increase based on their response or how much
swelling they have. If they have more severe
swelling or if they have significant vision loss, they're
not going to be able to have enough time to wait for these
(21:34):
other treatments that take longer to work.
So we need to do something quickly to relieve the pressure
on the optic nerves and that will often include some kind of
surgical treatment. But I wanted to go back and
touch a little bit about some ofthe points you made earlier.
For mild and even moderate vision loss, we usually
(21:56):
recommend weight loss is kind ofthe mainstay of our treatment.
Can you talk a little bit more about the weight loss?
Like what are your recommendations for people?
And also secondarily, what if someone is not overweight?
What do you recommend for them? So I guess they're kind of two
separate questions, but let's talk about the first one and
then the second one. Right.
(22:17):
So the where we get the amount of weight loss, kind of our
magic number really is by looking at previous research
studies with people with this condition.
And there was a research study in the late 1990s looking at
people who had idiopathic intracranial hypertension and
(22:41):
weight loss. And they found that the people
who had 6% of their body weight weight loss were the ones who
had the most improvement in their symptoms and in the
swelling of the optic nerves. So that's kind of the magic
number that we recommend for people to aim for.
(23:03):
And for most people, I mean, that's 6% is not a huge amount
of weight. For many of the patients who
have idiopathic intracranial hypertension, this can be
somewhere between 10 and 20 lbs.So it it is something that's
difficult but is attainable. We're not asking people to lose
(23:23):
100 lbs, you know? Absolutely.
And in the patient who have normal weight, we definitely
will look for other conditions that could potentially cause
idiopathic intracranial hypertension.
So we didn't discuss this earlier, but there is a whole
list of medications that can actually increase the
(23:45):
intracranial pressure. And this can include acne
medicines such as the tetracycline family like
Minocycline and doxycycline. So we will ask if they're on
these medications. Even sometimes retinols that are
used in skin creams for acne treatment can cause an increase
(24:06):
in in the intracranial pressure.The other thing that I asked
about is vitamin A supplements. So if you're taking the
recommended daily value of vitamin A, that's fine, but some
supplements have mega doses of vitamin A and this can also lead
to an increase in the pressure. So I will go through their whole
(24:30):
list of all their supplements and their medications and to
make sure that they're not taking something that could
raise the pressure. Additional risk factors.
This is a little bit controversial, but certain types
of oral contraceptives can contribute to an increase in the
(24:51):
pressure. So we always want to ask about
this, but the the increase is not as high as some of the other
medications that I discussed, maybe a 1% higher chance.
So those are not as critical to stop as the other medications
such as doxycycline. The other potential risk is
(25:15):
steroids. So using steroids, either using
them for a long time or taperingoff of steroid medications can
increase the pressure. So in patients who have more of
a normal weight, I will ask about these medications and and
try to stop them to help. Yeah.
(25:36):
And also back to what we were talking about before, to tie
this all back, if we find that the patient is on a particular
medication that may have put them at risk for this condition,
then we know that there's a cause, right.
So then it's no longer necessarily idiopathic.
And in those situations, sometimes we do call it pseudo
tumor cerebride because now we found why they have the high
(25:58):
pressure. And usually when we discontinue
that particular medication or supplement, then hopefully the
pressure will normalize. So that's also something
important. It's a small distinction, a
little bit of semantics, but I think it is important to
recognize that. Well, thank you for those
recommendations because I know that a lot of people, a lot of
(26:19):
my patients who have been newly diagnosed with IIH, they will
report weight gain. And many, many patients will
say, oh, in the past six months,yes, I've kind of gained weight
a little bit, anywhere from 10 to 15.
Even 20 lbs can sometimes make adifference and you know, if
someones on the edge of potentially developing this
condition, it can kind of lead them over the, you know, tip
(26:41):
them over and simply by losing those extra few pounds that can
make a big difference in gettingthis condition to hopefully go
into remission, which is the next thing I wanted to talk to
you about Doctor Elmalam. How?
Long. Do you expect people, let's say
they've been put on medication like Diamox, how long do you
expect people to stay on that? Like when, When can they be
(27:02):
stabilized and when can you potentially take them off the
medication? I think this is something that's
very individualized. So some patients will lose
weight and then their symptoms will get much better and they'll
be able to stop acetazolamide after only a few months.
(27:24):
Some patients will have a reallyhard time and every time they
try to stop the medication, their symptoms come back or
their swelling gets worse again.And it may take more time, like
maybe even a few years. But I definitely have patients
who are able to stop the medication and stay off of it.
(27:45):
And you know, I have some peopleI've been following for 5-10
years and they're still doing fine off the medication.
So you know that you don't have to lose hope that you're going
to be on this forever. But you know, unfortunately
there are a few patients that need to take it for several
years. And you know it if, if you're
(28:06):
benefiting from it and the swelling is under control and
your vision is normal, symptoms are good, you know, it's, it's
fine to take it for a few years,you know?
Yeah, I always tell patients, you know, the two approaches
work together, so there's weightloss and the medication.
(28:26):
So if you can achieve the weightloss goal, then we can taper you
off the medications. I've also seen patients where
they've successfully come off, they've lost weight, some
weight, and they've come off themedication.
Then they happen to regain weight a few years down the road
and then it flares up again. So that can happen.
For whatever reason, IIH tends to be very, very sensitive to
weight in certain individuals, don't you agree, Doctor Omalim?
(28:50):
Yes, definitely. Yeah.
And the other thing I wanted to touch upon with weight loss is
we talk about this magic number of 6%, but there was another
research study that looked at people who had bariatric surgery
and the amount of weight loss they had with that.
And they actually found that if they lost about 24% of their
(29:13):
body weight, they were basicallycured.
So they had normal pressure and.Great to hear.
Yeah. And nowadays, you know, we have
various options for weight loss.Now.
We also have these drugs called GLP, one receptor agonist, and
they have been very effective inhelping people lose weight.
So I've had quite a few patientswith IIH who also go into
(29:35):
remission and even cure being onsome of these medications.
Yes, yeah, absolutely. So Doctor Elmo, we have just a
few minutes left together. This has been so, so helpful in
in understanding IIH. You know what you've shared.
Do you have any other lifestyle tips you usually give your
patients who've been diagnosed with this condition?
(29:56):
Yeah, so many people think that if they they have to go into
this rigorous exercise routine to be able to lose weight, but
it's actually 80% diet. And and I tell people you don't
want to do it quickly, you want to do it slowly and you want to
(30:16):
actually just change your lifestyle.
And so, you know, following the low salt is important because a
lot of patients will find when they have a higher salt meal,
their symptoms will get worse. The pressure will go up.
So maintaining less than 2000 milligrams of sodium per day is
(30:37):
really important for this condition.
Having slow weight loss that will be effective and stay off
is important. And what has proven to really
work is doing some kind of program where you're tracking
what you're taking in and you kind of keep yourself
accountable. You don't have to go crazy and
(30:59):
weigh yourself multiple times a day, but I think weighing
yourself about once a week so that you know your overall
progress, I think it helps you stay on track.
And, you know, joining some kindof program where you have other
people to help support you also makes it more effective, so.
(31:22):
Yeah, I know those are great tips.
And actually I was involved in ain a large study called the
Idiopathic Intracranial Hypertension Treatment Trial,
IIHTT for short. And those patients were enrolled
in the study. They each got a weight loss
coach. So they each worked with a
weight loss coach during their time in the study.
(31:42):
And it made a big, big difference to help someone guide
you along the way who also helped with nutrition and, and
exercise, their movement goals. All of our patients had
pedometers, so they, they loggedin their steps that they walked
every day. So it does help, it is helpful
to have someone kind of guiding you along the journey or perhaps
(32:03):
joining a, a patient support group who can guide you or, or
weight loss support group. It makes a big difference
because then you're not doing iton your own.
Well, thank you, Doctor Elmolim,for all of these amazing
insights into IIH. It's really been so helpful for
our listeners to help understandthis condition that is just so
common these days in our patientpopulation.
(32:25):
If anyone wanted to reach out toyou to perhaps learn more,
perhaps even become a patient, how can they find you?
I have a website on the Mount Sinai website.
If you just do a search for my name, my full name, Valerie
Almalem, and actually there aren't too many people with my
last name. So even if you just search my
last name, you can find the Mount Sinai website that has the
(32:50):
My Office phone number, address and e-mail, and you can make an
appointment through there. Well, wonderful.
We will share that link in the show notes underneath the
podcast. So thank you again for joining
us. Doctor Elmom, it was really a
pleasure to chat with you today.Thank you so much for having me,
this was fun. Absolutely, and thank you all
for listening to the IQ Podcast.I will see you all next time for
(33:13):
our next episode, so stay tuned.Thank you for tuning into the IQ
Podcast. We hope you enjoyed today's
episode and learn something new to help elevate your IQ.
If you loved what you heard, don't forget to subscribe, leave
a review and share the podcast with your friends.
Stay connected with Doctor Ronnie Bannock for more eye
opening insights on eye health, nutrition and lifestyle.
(33:36):
Until next time, keep your vision clear and your IQ sharp.
Let me ask you this, have you ever experienced headaches that
are pressure like like a band sensation around your head along
with blurry vision, particularlyif you sit up too quickly or you
bend down to pick up something and come back up?
If your vision goes blurry with a pulsating sound in your ears,
like almost like water or a swishing sound like with your
(00:22):
heartbeat. Well, if you've had any of these
symptoms, you may, and I say may, you may have a condition
known as idiopathic intracranialhypertension, also known as IIH
for short. Well, to learn more about IIH,
I've invited one of my colleagues who's a leading
neuroophthalmologist, Dr. Valerie Elmolim, to join us on
(00:44):
the IQ Podcast. So stay tuned if you want to
learn more about IIH. Welcome to the IQ podcast,
hosted by Doctor Ronnie Bannock,America's integrative neuro
ophthalmologist. Get ready to explore the
intricate connections between the brain and the eye through
neuro ophthalmology. Journey with Doctor Ronnie into
(01:06):
the world of integrative ophthalmology, where cutting
edge science meets holistic Wellness.
Discover how to protect and preserve vision through powerful
preventative strategies based onice, smart nutrition, and
lifestyle modifications. Whether you're an eye care
provider or just curious about to maintain healthy vision so
you can see the world more clearly, join Doctor Ronnie for
(01:26):
exciting and eye opening discussions which will no doubt
raise your IQ. Welcome everyone to another
episode of the IQ Podcast. I'm your host, Doctor Ronnie
Vanik, and through this podcast,you'll learn insights about
vision health and brain health to help you raise your IQ.
Today I'm so excited to introduce our guest for this
(01:48):
episode, Doctor Valerie Elmalam.Thank you.
Thanks for having me. Welcome, Doctor El Mullim.
So Doctor El Mullim is an associate professor of
ophthalmology and director of neuro Ophthalmology at New York
Ioneer of Mount Sinai Hospital System.
She's very involved with teaching medical students and
residents as well as educating her peers at national meetings.
(02:11):
So we are so honored to have youwith us today.
And I always like to start off by asking our guest, Doctor El
Mullim, what was it that inspired you to go into your
field? So was there like a particular
moment or patient that you'd seen that made you want to
pursue neuro ophthalmology as a subspecialty?
So I always loved neuroscience, even growing up.
(02:35):
I was always a fan of science ingeneral since I was very little.
I think maybe around 4 years oldis when my parents started told
me that I became interested in medicine in general.
I don't know that there was necessarily any specific events
that made me interested, but initially I wanted to pursue
(02:58):
neurosurgery because I liked anatomy and I really liked
neuroscience. And then there was actually a
surgeon in medical school who told me to look into
ophthalmology and told me that there was a lot of neuroscience
involved in ophthalmology and a little bit of an easier
(03:20):
lifestyle. Absolutely.
So when I did my rotation in ophthalmology as a medical
student, everybody was so happy with their field and the
patients were very grateful for being able to have the gift of
sight. So I still wanted to integrate
(03:44):
my interest in neuroscience and became interested in pursuing
neuro ophthalmology. Well, that's wonderful and I'm
so glad you decided to pursue ophthalmology and neuro
ophthalmology rather than neurosurgery.
It's wonderful to have you as a colleague, you know, Doctor Elmo
Lemon actually, and I actually work side by side at our
hospital. So it's, it's really a pleasure.
(04:05):
So Doctor Elmo for today's episode on the IQ podcast, we're
we're focusing on this conditionknown as idiopathic intracranial
hypertension. It's a mouth mouthful, but we
call it IIH for short. Can you give our listeners a
general overview of what is thiscondition IIH?
And then we'll go into some moreof the details, but just give us
(04:26):
first like an overview, like a 30,000 foot view of what this
is. So, idiopathic intracranial
hypertension is a neurologic condition where you have
elevated pressure in the cerebral spinal fluid.
So elevated intracranial pressure and this pressure gets
transmitted to your optic nerves, which are the nerves
(04:49):
that connect the eye to the brain.
And when the pressure is high, it causes swelling of your optic
nerves and this can threaten vision.
This condition is common in younger women in their 20s,
thirties and 40s who are overweight and we don't know the
(05:11):
exact reason why we have an association with being
overweight, but we know that with weight loss this condition
often improves and even goes away.
And some of the treatments are targeted towards lowering the
pressure in the cerebral spinal fluid so we can relieve the
(05:32):
pressure on the optic nerves. Well, thank you for that.
That was so enlightening. So you mentioned that this
condition is associated with high pressure in the brain.
Now there are other conditions also that may cause similar
symptoms or high pressure in thebrain as well.
So how do you distinguish between IIH versus some of those
(05:53):
other conditions that may potentially be not just vision
threatening, but even life threatening?
How can you tell the difference?Right.
So as part of the evaluation in someone who has swelling of the
optic nerves, we want to see if they have any other conditions
other than idiopathic intracranial hypertension.
(06:14):
And that could include a tumor like a brain tumor that could be
increasing the pressure or even causing direct pressure on the
optic nerves. It could be a blood clot in the
veins that drain the fluid from,you know, those cerebral spinal
(06:34):
fluid and that can cause a backup and a build up of
pressure. So we, we look for those
conditions by doing an MRI of the brain with contrast so that
we can see if there's a tumor there.
And we also do an MRV or an Mr. venogram where we look at the
(06:55):
blood vessels, the veins that drain the fluid from the the
cerebral spinal fluid and we cantell if there is a tumor or a
blood clot that would be causingthe increase and the pressure
and you won't see those things. That's when we think about
idiopathic intracranial hypertension.
(07:18):
So basically you're saying, Doctor Elmalam, that the patient
has to undergo these specific tests before we can call this
idiopathic. By the way, for our listeners,
idiopathic means we don't reallyknow what causes it.
So there's an unknown there. There's no specific 'cause I
wanted to ask you a little bit about, you know, IIH has been
known by many different terms inthe past.
(07:40):
And one of the terms we commonlyused to use for this was pseudo
tumor cerebri. So can you tell us a little bit
about pseudo tumor cerebri, whatit, what that entity is and
whether, you know, we still use that term sometimes or how is it
different than IIH or maybe there's overlap?
Can you shed some light on that?Yeah, there there are people
(08:01):
that still refer to it interchangeably with pseudo
tumor, cerebri and idiopathic intracranial hypertension.
But the term pseudo tumor is problematic because it is the,
the term pseudo is basically saying like, so it's they're
saying that it's behaving like if you have a brain tumor.
(08:24):
And I think that term can be a little bit scary for patients.
And you know, it doesn't necessarily refer to all of the
underlying conditions that that can cause swelling of the optic
nerves. So there are still people that
refer to it as pseudo tumor cerebri, but I think the more
(08:44):
accepted term is idiopathic intracranial hypertension.
The other term that it used to be called is benign
entrepreneurial attention, and we definitely do not use that
term anymore because it's not always a benign condition
because you can lose vision fromit.
Yeah, I think that's so important for people to realize
(09:07):
and, and hopefully that term benign has really fallen out of
favor. I know that there's still some
perhaps older practicing doctorswho still use that term, but it
certainly is not benign because it can cause not just vision
issues, but other neurologic symptoms as well.
Let's talk about just specifically.
So now we're just talking about idiopathic endocrinial
(09:28):
hypertension. You mentioned some of the risk
factors. What are some of the symptoms
that can happen that patients may experience with this
condition? Yeah.
The most common symptom is headache, which occurs in over
80% of patients who have idiopathic intracranial
hypertension. And the specific type of
(09:49):
headache that you get is worse when you wake up in the morning.
And the reason for this is because you've been laying down
all night, so the pressure in your head is a little bit higher
when you're first waking up. So sometimes this headache can
even wake them up not from sleeping.
It's usually a pounding or throbbing headache.
(10:12):
Some people will complain of pressure behind the eyes.
And then the other common symptom you can have is a
swishing noise in your ears, which can occur around the same
time as your heartbeat. So we call it pulsatile tinnitus
or pulp ankle tinnitus. So I started to interrupt, but
(10:36):
not like a high pitched ringing in the ear.
This is a different type of sound, correct?
Because a lot of people have a high pitched ringing in the
ears. It's very common.
Right, exactly. And I'll, I'll usually ask
people if they hear sort of likethe sound of the ocean, you
know, it's more of a swishing than the high pitched ringing or
buzzing that you may get with tinnitus that can be associated
(11:00):
with ear problems. Another symptoms that you can
have is more common in people who have more swelling of the
optic nerves, which is called transient visual obscurations.
What this is is when you change position.
So if you stand up quickly or ifyou come to a sitting position
(11:22):
from laying down, sometimes you can get a temporary blackout or
white out of the vision that lasts just a couple seconds and
then comes back. Some people will describe seeing
spots in their vision instead ofthis black out or white out of
vision, but they're temporary changes in the vision that occur
(11:43):
due to swelling of the optic nerve, and this is because of
the pressure on the blood vessels supplying the eye from
all that swelling. Yeah, this last week actually, I
saw a patient with newly diagnosed IIH and she described
she would have these transient blackouts whenever she bent down
to either like tie her shoe or pick something up off the floor.
(12:05):
She would bend down for just a few seconds, get back up, and
everything would just be Gray and pixelated.
And then her vision would come back into into focus.
So again, positional changes arereally key there.
Some other symptoms that people can have, they can have
dizziness, they can have neck stiffness when the pressure is
(12:26):
really high and and rarely but it can occur.
You can have some some changes in concentration or cognitive
changes that occur with the highpressure.
Absolutely. Now I wanted to talk a little
bit more about the headache because many people get
headaches of all kinds, whether it be tension headache or
(12:47):
migraine headache. How can one differentiate
headache that's from high pressure in the brain that may
be from IIH versus a migraine? Are there specific symptoms that
they should be watching out for?Yeah.
So as I mentioned before, the headache that is associated with
the high pressure very commonly can occur when you're laying
(13:09):
down or right when you're wakingup in the morning.
So if your headache is worse right when you wake up and then
it goes away after about an houror two when you've been standing
for a while, that can be a symptom to look out for.
And sometimes people have worsening headache when they're
changing position, like if they're bending down, as you
(13:32):
mentioned, when with your patient who had the change in
vision with bending, the headache can also get worse with
changes in position. So my, this is as opposed to
migraine where it can occur at any time of the day.
And you, some people will get a warning sign that they're
getting a migraine, like some zigzags or changes in their
(13:55):
vision, or they'll get pain, youknow, behind one eye and then
it'll spread to the other side. And they usually will get better
with certain types of medication, but can be
associated with nausea, light sensitivity, activity, and sound
sensitivity. So there can be some overlap
(14:16):
with migraines. So many people who get
idiopathic intracranial hypertension, you know, are
young women and young women alsocommonly have migraines.
So there certainly can be overlap, but the the
differentiating feature is the headache will get worse with
changing position. And I think have that, then
(14:39):
that's something to really look into.
Yeah, those are some great tips,Doctor Elmolim.
I've actually had a lot of patients who have had a previous
diagnosis of migraine for many years, or perhaps, you know, a
new diagnosis of migraine, then they slowly notice that there
are headache changes in its characteristics and they
ultimately get diagnosed with IIH.
(14:59):
So it is possible to have two together, both of the conditions
together. But many patients can
differentiate the type of headache that they're getting
like, oh, this is my pressure headache versus this is my
migraine headache. So you just really have to pay
attention to your symptoms and maybe, you know, keep a log, jot
them down and try to identify the pattern that's happening.
(15:20):
That may help you identify the cause.
So Doctor Elmo, you talked earlier about a couple of tests
that need to be done to diagnosethis condition.
IIH from a, so you mentioned like for example, MRI, you
mentioned Spinal Tap. What about vision tests?
Like from a neuro ophthalmologist perspective,
which vision tests do you rely on the most to help monitor
(15:42):
these patients and and and watchtheir vision?
Yeah. So we will check the vision on
the eye chart, the visual acuity.
We will do a peripheral vision test called a visual field,
where we test not just the center but also the peripheral
(16:03):
vision because commonly in idiopathic intracranial
hypertension, the first vision to be affected is actually the
peripheral vision, not the center vision.
So many times people won't even know, they won't even be aware
that they have peripheral visionloss until it gets closer to the
(16:23):
center and then you know, it's, it's later on in their, in their
course and we really want to catch it early.
The other test we look for is color vision because in optic
nerve conditions you can have decreased color vision when it's
a little bit more advanced. And we also do some pictures of
(16:45):
the optic nerve. One of the pictures that we rely
on mostly to tell if things are getting better or worse is the
Oct test, which is optical coherence tomography.
This is a picture where we can actually measure the thickness
and look at the configuration ofthe optic nerve to tell if there
(17:09):
is worsening or improving swelling.
And. By the configuration of the
optic nerve on this test, we canalso tell if there is high
pressure like the cerebral spinal fluid that's kind of
pushing on the optic nerve to change its configuration, you
(17:29):
know, moving up rather than the normal configuration which is
down. So we really rely on this test
heavily for following, for firstdiagnosing and also for
following patients with idiopathic intracranial
hypertension. Well, thank you for sharing
those. So again, just to recap what
Doctor Elmalim said, we check vision, we check color vision,
(17:54):
We also check pupils and we checked the field, which is
very, very important. And perhaps the most important
test that we do is we monitor the peripheral vision and then
we do imaging of the optic nervesuch as an Oct test and
sometimes even photographs of the optic nerve to document how
much swelling there is. You've been.
Listening to the IQ Podcast withme, Doctor Ronnie Banik.
(18:16):
We're going to take a short break and then we'll be right
back with more insights to help you raise your IQ.
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(19:19):
your migraine naturally. Welcome back everyone to the IQ
Podcast. Today we're chatting with Doctor
Valerie Elmalem, a leading neuroophthalmologist and expert in
IIH. So Doctor Elman, we've talked
about what may be risk factors for IIH, what it is, what the
symptoms are, what the findings are on eye exams.
(19:41):
Now let's talk about treatment because I know that's what
people want to know about, you know, how can I take care of
this? Can it make, can I make it go
away? What can be done?
So when you first see a patient,what are some options that you
consider for treatment for IH? The the treatment options that I
discussed with patients really depends on their vision and also
(20:04):
the amount of swelling of their optic nerves.
So we have a grading system for the amount of swelling of the
optic nerves. And just, you know, to give you
an overview, you can have mild, moderate or severe swelling.
And in the more mild category where people do not have any
(20:25):
changes in their peripheral vision and they have normal
vision and relatively mild symptoms.
Sometimes I will consider just advising a low salt diet and
weight loss to as treatment. And then I follow them closely
to see if they're getting better.
The next step up would be to addon a medication called
(20:49):
acetazolamide, which is a water pill, a diuretic that decreases
the production of the cerebral spinal fluid to decrease the
pressure. And that we still also recommend
the diet and the weight loss, the low salt diet and weight
loss in addition to using the acetazolamide.
(21:10):
And we can start with a lower dose of 500 milligrams twice a
day and then increase based on their response or how much
swelling they have. If they have more severe
swelling or if they have significant vision loss, they're
not going to be able to have enough time to wait for these
(21:34):
other treatments that take longer to work.
So we need to do something quickly to relieve the pressure
on the optic nerves and that will often include some kind of
surgical treatment. But I wanted to go back and
touch a little bit about some ofthe points you made earlier.
For mild and even moderate vision loss, we usually
(21:56):
recommend weight loss is kind ofthe mainstay of our treatment.
Can you talk a little bit more about the weight loss?
Like what are your recommendations for people?
And also secondarily, what if someone is not overweight?
What do you recommend for them? So I guess they're kind of two
separate questions, but let's talk about the first one and
then the second one. Right.
(22:17):
So the where we get the amount of weight loss, kind of our
magic number really is by looking at previous research
studies with people with this condition.
And there was a research study in the late 1990s looking at
people who had idiopathic intracranial hypertension and
(22:41):
weight loss. And they found that the people
who had 6% of their body weight weight loss were the ones who
had the most improvement in their symptoms and in the
swelling of the optic nerves. So that's kind of the magic
number that we recommend for people to aim for.
(23:03):
And for most people, I mean, that's 6% is not a huge amount
of weight. For many of the patients who
have idiopathic intracranial hypertension, this can be
somewhere between 10 and 20 lbs.So it it is something that's
difficult but is attainable. We're not asking people to lose
(23:23):
100 lbs, you know? Absolutely.
And in the patient who have normal weight, we definitely
will look for other conditions that could potentially cause
idiopathic intracranial hypertension.
So we didn't discuss this earlier, but there is a whole
list of medications that can actually increase the
(23:45):
intracranial pressure. And this can include acne
medicines such as the tetracycline family like
Minocycline and doxycycline. So we will ask if they're on
these medications. Even sometimes retinols that are
used in skin creams for acne treatment can cause an increase
(24:06):
in in the intracranial pressure.The other thing that I asked
about is vitamin A supplements. So if you're taking the
recommended daily value of vitamin A, that's fine, but some
supplements have mega doses of vitamin A and this can also lead
to an increase in the pressure. So I will go through their whole
(24:30):
list of all their supplements and their medications and to
make sure that they're not taking something that could
raise the pressure. Additional risk factors.
This is a little bit controversial, but certain types
of oral contraceptives can contribute to an increase in the
(24:51):
pressure. So we always want to ask about
this, but the the increase is not as high as some of the other
medications that I discussed, maybe a 1% higher chance.
So those are not as critical to stop as the other medications
such as doxycycline. The other potential risk is
(25:15):
steroids. So using steroids, either using
them for a long time or taperingoff of steroid medications can
increase the pressure. So in patients who have more of
a normal weight, I will ask about these medications and and
try to stop them to help. Yeah.
(25:36):
And also back to what we were talking about before, to tie
this all back, if we find that the patient is on a particular
medication that may have put them at risk for this condition,
then we know that there's a cause, right.
So then it's no longer necessarily idiopathic.
And in those situations, sometimes we do call it pseudo
tumor cerebride because now we found why they have the high
(25:58):
pressure. And usually when we discontinue
that particular medication or supplement, then hopefully the
pressure will normalize. So that's also something
important. It's a small distinction, a
little bit of semantics, but I think it is important to
recognize that. Well, thank you for those
recommendations because I know that a lot of people, a lot of
(26:19):
my patients who have been newly diagnosed with IIH, they will
report weight gain. And many, many patients will
say, oh, in the past six months,yes, I've kind of gained weight
a little bit, anywhere from 10 to 15.
Even 20 lbs can sometimes make adifference and you know, if
someones on the edge of potentially developing this
condition, it can kind of lead them over the, you know, tip
(26:41):
them over and simply by losing those extra few pounds that can
make a big difference in gettingthis condition to hopefully go
into remission, which is the next thing I wanted to talk to
you about Doctor Elmalam. How?
Long. Do you expect people, let's say
they've been put on medication like Diamox, how long do you
expect people to stay on that? Like when, When can they be
(27:02):
stabilized and when can you potentially take them off the
medication? I think this is something that's
very individualized. So some patients will lose
weight and then their symptoms will get much better and they'll
be able to stop acetazolamide after only a few months.
(27:24):
Some patients will have a reallyhard time and every time they
try to stop the medication, their symptoms come back or
their swelling gets worse again.And it may take more time, like
maybe even a few years. But I definitely have patients
who are able to stop the medication and stay off of it.
(27:45):
And you know, I have some peopleI've been following for 5-10
years and they're still doing fine off the medication.
So you know that you don't have to lose hope that you're going
to be on this forever. But you know, unfortunately
there are a few patients that need to take it for several
years. And you know it if, if you're
(28:06):
benefiting from it and the swelling is under control and
your vision is normal, symptoms are good, you know, it's, it's
fine to take it for a few years,you know?
Yeah, I always tell patients, you know, the two approaches
work together, so there's weightloss and the medication.
(28:26):
So if you can achieve the weightloss goal, then we can taper you
off the medications. I've also seen patients where
they've successfully come off, they've lost weight, some
weight, and they've come off themedication.
Then they happen to regain weight a few years down the road
and then it flares up again. So that can happen.
For whatever reason, IIH tends to be very, very sensitive to
weight in certain individuals, don't you agree, Doctor Omalim?
(28:50):
Yes, definitely. Yeah.
And the other thing I wanted to touch upon with weight loss is
we talk about this magic number of 6%, but there was another
research study that looked at people who had bariatric surgery
and the amount of weight loss they had with that.
And they actually found that if they lost about 24% of their
(29:13):
body weight, they were basicallycured.
So they had normal pressure and.Great to hear.
Yeah. And nowadays, you know, we have
various options for weight loss.Now.
We also have these drugs called GLP, one receptor agonist, and
they have been very effective inhelping people lose weight.
So I've had quite a few patientswith IIH who also go into
(29:35):
remission and even cure being onsome of these medications.
Yes, yeah, absolutely. So Doctor Elmo, we have just a
few minutes left together. This has been so, so helpful in
in understanding IIH. You know what you've shared.
Do you have any other lifestyle tips you usually give your
patients who've been diagnosed with this condition?
(29:56):
Yeah, so many people think that if they they have to go into
this rigorous exercise routine to be able to lose weight, but
it's actually 80% diet. And and I tell people you don't
want to do it quickly, you want to do it slowly and you want to
(30:16):
actually just change your lifestyle.
And so, you know, following the low salt is important because a
lot of patients will find when they have a higher salt meal,
their symptoms will get worse. The pressure will go up.
So maintaining less than 2000 milligrams of sodium per day is
(30:37):
really important for this condition.
Having slow weight loss that will be effective and stay off
is important. And what has proven to really
work is doing some kind of program where you're tracking
what you're taking in and you kind of keep yourself
accountable. You don't have to go crazy and
(30:59):
weigh yourself multiple times a day, but I think weighing
yourself about once a week so that you know your overall
progress, I think it helps you stay on track.
And, you know, joining some kindof program where you have other
people to help support you also makes it more effective, so.
(31:22):
Yeah, I know those are great tips.
And actually I was involved in ain a large study called the
Idiopathic Intracranial Hypertension Treatment Trial,
IIHTT for short. And those patients were enrolled
in the study. They each got a weight loss
coach. So they each worked with a
weight loss coach during their time in the study.
(31:42):
And it made a big, big difference to help someone guide
you along the way who also helped with nutrition and, and
exercise, their movement goals. All of our patients had
pedometers, so they, they loggedin their steps that they walked
every day. So it does help, it is helpful
to have someone kind of guiding you along the journey or perhaps
(32:03):
joining a, a patient support group who can guide you or, or
weight loss support group. It makes a big difference
because then you're not doing iton your own.
Well, thank you, Doctor Elmolim,for all of these amazing
insights into IIH. It's really been so helpful for
our listeners to help understandthis condition that is just so
common these days in our patientpopulation.
(32:25):
If anyone wanted to reach out toyou to perhaps learn more,
perhaps even become a patient, how can they find you?
I have a website on the Mount Sinai website.
If you just do a search for my name, my full name, Valerie
Almalem, and actually there aren't too many people with my
last name. So even if you just search my
last name, you can find the Mount Sinai website that has the
(32:50):
My Office phone number, address and e-mail, and you can make an
appointment through there. Well, wonderful.
We will share that link in the show notes underneath the
podcast. So thank you again for joining
us. Doctor Elmom, it was really a
pleasure to chat with you today.Thank you so much for having me,
this was fun. Absolutely, and thank you all
for listening to the IQ Podcast.I will see you all next time for
(33:13):
our next episode, so stay tuned.Thank you for tuning into the IQ
Podcast. We hope you enjoyed today's
episode and learn something new to help elevate your IQ.
If you loved what you heard, don't forget to subscribe, leave
a review and share the podcast with your friends.
Stay connected with Doctor Ronnie Bannock for more eye
opening insights on eye health, nutrition and lifestyle.
(33:36):
Until next time, keep your vision clear and your IQ sharp.
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