Neuro-Opthalmology: Papilloedema

Question 1

What are the causes of papilloedema?

Answer 1

• Intracranial mass – benign or cancerous tumour
• Hydrocephalus – dilation of ventricles – can put pressure on CSF
• Central nervous system infection e.g. Meningitis
• Trauma
• Infiltration e.g. leukaemia, sarcoidosis
• Benign intracranial hypertension:
  o Raised ICP in absence of an intracranial mass, lesion or hydrocephalus & normal CSF constituents
  o Not life threatening but permanent, often severe, visual damage (fields more than VA)
  Can be life-threatening

Question 2

What are the symptoms of papilloedema?

Answer 2

• Occasionally asymptomatic – could be picked up in routine exam – may be early stage of papilloedema
• Headaches:
  o ‘muzzy headed’ at start & then develop into extreme pain, usually presenting at hospital within 6 weeks
  o Characteristically in morning, waking up px – lying down & pressure in brain increases
  o Generalised or localised – no pattern – not one single position that it may be
  o Worse when pressure increases: moving head, bending over e.g. to tie shoelaces, coughing
  o Very rarely headache absent
• Nausea & Vomiting:
  o Often projectile
  o May partially/temporarily relieve headache – gets slightly better when px is sick
  o Could occur at time of headache onset or earlier – up to few months
• Deterioration of consciousness:
  o From slight (drowsy) to dramatic loss of consciousness
• Pulsatile tinnitus – ringing in ears
• Vision:
  o Visual symptoms often absent – px may just have headache or nausea
  o Transient visual loss – could be papilloedema or TIA (differential diagnosis)
  o Horizontal diplopia – 6th nerve palsy induced by raised ICP
  o Constriction of visual field – pressure building up & pressing on nerves
   Px often won’t notice this constriction
  o Altered colour perception
  o Reduced VA in later stages
   Only get reduced VA when macular fibres are affected – macular fibres run in centre of optic nerve (they are protected to some extent)

Question 3

What are the stages of papilloedema?

Answer 3

Acute/early
Acute/established
Chronic
Atrophic
If catch the papilloedema early enough, it does not have to go through all the stages – it can recover w/o atrophy depending on the damage that has occurred

Question 4

Describe acute/early papilloedema?

Answer 4

• Symptoms:
  o Headache
  o Nausea & vomiting
  o Vision normal & no visual symptoms
• Examination:
  o VA usually normal
  o Colour vision usually normal
  o Pupil responses normal
• Disc appearance:
  o Hyperaemia – increased redness
  o Dilatation of capillary net
  o Oedematous retinal nerve fibre layer seen as obscuration of disc edge & vessels – vessels drape over edge of disc
  o Mild elevation
  o Absent Spontaneous Venous Pulsation (SVP):
   Look at BVs as they come out cup  look under high mag & should see it pulsing as blood travels through BVs
   If SVP is present, papilloedema unlikely
   Absence of SVP does not confirm papilloedema as 20% of normal individuals don’t have this
   Loss of previous SVP more indicative of papilloedema
  H&S, one or both eyes and timing of onset will help identify papilloedema – all types of optic disc oedema look fairly similar

Question 5

Describe acute/established papilloedema?

Answer 5

• Symptoms:
  o As early, but includes:
   Transient visual disturbance, lasting seconds
• Examination:
  o As early, but includes:
   Visual fields: enlargement of blind spot
• Fundus appearance:
  o As early, but includes:
   Severe hyperaemia
   Moderate elevation, enlarged optic nerve & retinal folds
   Peripapillary flame shaped haemorrhages & cotton wool spots
   Hard exudates in macular fan w/ temporal part missing
• Fan shaped appearance round macula – those fibres are becoming affected

Question 6

Describe chronic papilloedema?

Answer 6

• Present for a while
• Symptoms:
  o Vision variable (can be okay or reduced), fields restricted
• Examination:
  o Gradual deterioration in optic nerve function
  o VA variable – varies from 6/12 to 6/60
  o Visual fields:
   Nasal loss
   Arcuate defect
   Generalised depression – generally the function of the nerves is reduced – overall sensitivity of light eye can see is reduced – light needs to be brighter for them to 1st detect it
   Central loss a late finding
• Disc appearance:
  o Pale due to axonal loss – secondary optic atrophy
  o Marked elevation of discs
  o Absence of cotton wool spots & haemorrhages
  o Optociliary shunt vessels/collateral vessels
   Pre-existing venous channels – these start dilating up to try & supply blood to the areas that are getting damaged
   Chronic central retinal vein obstruction – veins & arteries go through centre of ONH – can be pressure on them due to the swelling
   Refractile bodies at disc due to chronic lipid rich exudation – yellow deposits of lipid – lots of exudates joining up into bigger refractile bodies

Question 7

Describe atrophic papilloedema (secondary to optic atrophy)?

Answer 7

• Permanent affect on nerves
• Symptoms/examination:
  o VA, fields etc severely reduced due to loss of nerves
• Optic disc appearance:
  o Pale/grey optic nerve
  o Possibly mild elevation, indistinct margins

Question 8

What is the management of papilloedema?

Answer 8

• Same day referral to ophthalmologist –> Tx of cause – many of them are life-threatening