Purpose: To test the hypothesis that puberty is a risk factor for poorer visual outcome in idiopathic intracranial hypertension (IIH). Design: Retrospective chart review case series. Methods: setting: Tertiary referral center, neuro-ophthalmology unit. patient population: Ninety-six patients with IIH followed for a minimum of one year. observation: Age (grouped into prepubertal, pubertal, teenage, or adult), obesity, initial intracranial pressure (ICP), measurements and presence of hypertension, anemia, or renal failure were correlated with final visual outcome using χ2, stepwise logistic regression, and model-selection log linear analyses. main outcome measures: Visual outcome was graded into "excellent" -no evidence of an optic neuropathy or any permanent visual field defect in either eye, "moderate"-evidence of an optic neuropathy and/or a mild (nasal constriction) visual field defect, or "poor outcome" (peripheral constriction)- permanent visual field defect. Results: Outcome data were complete for 96 patients. Moderate to poor visual outcome, as opposed to excellent, was significantly associated with puberty (P = .007 using the gender-specific definition of puberty, .0002 using the broad definition). Moderate-poor visual outcome occurred in none of seven IIH patients of prepubertal age (<9 years), in 15 of 26 patients presenting between nine to 16 years, in two of six patients aged 17 to 22 years, and in seven of 57 adult patients over the age of 23 years. Conclusions: In this series of 96 patients with IIH, visual outcome was less favorable in pubertal patients than in prepubertal, teenage, and adult patients. We recommend that clinicians maintain a high index of awareness when caring for pubescent children with IIH.