Would you recommend medical therapy for asymptomatic idiopathic intracranial hypertension with completely normal visual field testing?

If this patient has asymptomatic papilledema from idiopathic intracranial hypertension, then I might focus on weight loss first, which can be curative. I would follow her visual fields closely, however, and would have a low threshold to start acetazolamide if any change in her visual fields is noted.

(The scenario described is a little bit unusual though ...)

Vision-threatening papilledema is the leading indication for the treatment of intracranial hypertension (IIH). To assess visual function, most clinicians rely on automated (30-2 or 24-2) visual fields or corrected Snellen visual acuity. The latter measures central visual function and is not usually affected in early papilledema unless there is associated macular edema.

In one study of 79 patients with IIH, 84% had a mean deviation of -7dB or better on automated perimetry. (Mikkilineni et al., PMI...