Papilledema - Dr Shylesh Dabke

Papilledema
Dr Shylesh B Dabke
Resident Dept. of Ophthalmology
Kasturba Medical College
Mangalore

Definition
▪ Passive hydrostatic non inflammatory swelling of optic
nerve head secondary to raised intracranial pressure.
▪ Usually bilateral ; may be unilateral.
▪ Optic disc swelling in the absence of raised intracranial
pressure is referred to as optic disc edema.

Pathophysiology
 Disturbance in axoplasmic flow causing stasis swelling of axons and
leakage.
 Increased intracranial pressure(ICT) is transmitted along subarachnoid
space with optic nerve sheath acting as a tourniquet.
 Increased ICT leads to increased optic nerve tissue pressure which
alters pressure gradient resulting in stasis.

Theories of Genesis
 Mechanical Theory
 Ischemic Theory
 In most cases combined mechanism operates.

Causes(Bilateral)
 Space occupying lesions.
 Blockage of CSF flow.
 Reduction in CSF resorption.
 Increased CSF production.
 Idiopathic Intracranial Hypertension.
 Focal or diffuse cerebral edema.
 Reduction in size of CranialVault.
 Vitamin A toxicity.

Causes(Unilateral)
 Foster kennedy syndrome
 Previous unilateral optic atrophy.
 Posterior fossa tumor.
 Brain abcess.
 Subarachnoid haemorrhage.
 Optochiasmatic choroiditis.

Symptoms(Ocular)
 Transient obscuration of vision.
 Central vision affected late.
 Horizontal Diplopia.
 Visual Acuity

Symptoms(General)
 Headache more in the morning, intensifies with head
movement, coughing or straining.
 Projectile vomiting.
 Loss of consciousness/ generalized motor rigidity.

Signs(Mechanical)
 Elevation of the optic disc.
 Blurring of the optic disc margin.
 Filling in of the physiological cup.
 Edema of the peripapillary nerve fiber layer.
 Retinal or choroidal folds(Paton’s lines)
 Macular fan.

Signs(Vascular)
 Hyperemia of the optic disc.
 Vascular congestion.
 Peripapillary haemorrhage.
 Exudates in the disc or peripapillary area.
 Nerve fiber layer infarcts.

Grading of Papilledema
(according to severity and its
chronicity)

Early Papilledema
 Disc elevation.
 Venous distention and
tortuosity.
 Obscuration of the normal
disc margin and overlying
retinal vessels.
 Absence of spontaneous
venous pulsations

Established Papilledema
 Marked elevation of nerve
head with blurring of margins.
 Engorged tortous venules.
 Peripapillary splinter
hemorrhages.
 Cotton wool spots.
 Hard exudates over the disc
and macular area.

Chronic Papilledema(Classical
“Champagne cork appears of disc)
 disc hyperemia decreases
and disc progressively
appears pale in color.
 Opticociliary shunts and
drusen like deposits may be
present on the disc.
 High water mark.

Atropic Papilledema
 Onset of optic disc pallor
(secondary optic atrophy) .
 Decrease in disc haemorrhage.
 Narrowing of blood vessels
and their ensheating.
 Optic disc appears dirty white
and blurred due to glial
reaction.

Papilledema Grading System
(Frisen Scale)

Grade 0
 Mild nasal NFL elevation.
 Rare obscuration of a portion
of major vessel
(usually at superior pole)

Grade 1 (Very early Papilledema)
 Obscuration of nasal
border of disc
 Normal temporal disc
margin

Grade 2 (Early papilledema)
 Obscuration of all the disc
borders
 Elevation of nasal border
 No major vessel obscuration

Grade 3 (Moderate papilledema)
 Obscuration of all borders
 Increased diameter of optic
nerve head
 Obscuration of segment of
major blood vessels as they
pass disc margin.

Grade 4 (Marked papilledema)
 Elevation of entire nerve head
 Obscuration of all the borders
 A segment of major vessel
obscured on the disc

Grade 5 (Severe papilledema)
 Anterior extension of optic
nerve head
 Total obscuration of vessel on
disc surface
 Obliteration of optic cup.

Histopathological Findings
Acute disc edema
 Accumulation of extracellular fluid in and anterior to retinal lamina cribrosa,
with enlargement of subarachnoid space with stretching.
 Engorgement of axons occurs in prelaminar portion.

 Sensory retinal changes
- Displacement of retina away
from optic disc.
- Buckling of the outer layers
of retina.
- Displacement of rods and
cones away from their anchor
near Bruch’s membrane.
- Serious RD in peripapillary area.

 Electron microscopy of axons
- Axonal swelling and
accumulation of mitochondria.
- Mitochondrial swelling and
disruption.
- Disruption of fascicles of the
microtubules.

Chronic disc edema
 Degenerative and fibrotic changes in both anterograde and retrograde manner.
(hence atropy may occur anywhere from retinal nerve fiber layer to optic nerve)

 Enlargment of blind spot.
 Earliest loss of visual field
commonly involves inferior
nasal quadrent.
 Peripheral concentric
constriction.

 Relative scotoma (first to green and red).
 Complete blindness.
 In all cases visual field changes should be monitored carefully and decompression
to be done before peripheral constriction sets in.

Differential diagnosis of Papilledema
 Papillitis.
 Pseudopapilledema.
- Drusen of optic disc.
- High Hypermetropia (crowded nerve fibers at disc).
- AION.
 Optic neuritits.
 Tilted optic disc.
 Hypoplastic disc.
 Myelinated nerve fibers.

 Pseudopapilledema
- Drusen of Optic disc

 Pseudopapilledema
- Hyperopic disc

 History and physical examination including blood pressure measurement.
 Ophthalmic examination - In addition to fundus examination, assessment of
visual acuity, pupillary examination, ocular motility & alignment, and
visual fields.
 MRI with or without contrast is the best investigation of choice.
Investigations

CT Scan  To rule out
- Intracranial lesions.
- Obstructive hydrocephalus.
 Can detect
- Subarachnoid, epidural
& subdural hemorrhages.
- Acute infarctions.
- Cerebral edema. Contraindication for MRI.

Lumbar puncture
 Diagnostic
- Recording opening pressure.
 CSF for microbial and
infectious studies.
 Therapeutic procedure
- Pseudotumor cerebri

 Fundus Fluoroscence Angiography(FFA)
Early Phase
disc capillary dilation
Dye leakage spots
Microaneurysm over the disc
Late Phase
Leakage of dye beyond disc margin
Pooling of dye around the disc

 Treatment directed at underlying cause.
 Timely intervention has a remarkable effect on prognosis.
(unless nerve is irreversibly damaged)
 Vision recovery is faster then subsidence of fundus features.
Treatment

 BrainTumor
- Craniotomy to remove tumor.
 Resolution of papilledema within 6-8weeks.

 Pseudotumor Cerebri
- Surgical
Repeated Lumbar puncture
Decompression
Shunting procedure
 Resolution of papilledema within 2-3weeks of shunt procedure.
- Medical
Acetazolamide
Oral Glycerol
Corticosteroids
Weight reduction

 Papilledema in PIH
 General – bed rest.
 Control of BP.
 Control of edema – Diuretic, Hypertonic glucose.
 Non responders –Termination of pregnancy.

Surgical Decompression
 Indications  Failure of Medical treatment
- Marked disc swelling(>5D)
- Engorged veins
- Extensive hemorrhages
- Early exudate spots
- Progressive headache
 Progressive optic neuropathy
(early field constriction)
 Direct Fenestration of optic nerve sheath.

Therapeutic success
 Relief of headache.
 Transient visual obscuration decreased.
 Stability/ improvement of field defects.

Papilledema - Dr Shylesh Dabke

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