Papilledema

Question 1

What is the first thing you do if someone has bilateral disc edema in your office

Answer 1

Check BP immediately in order to r/o malignant HTN

Question 2

Malignant HTN

Answer 2

Defined as dangerously high BP >220mmHg systolic and/or >120mmHg diastolic. The patient must be hospitalized immediately due to the high risk of stroke

Question 3

If someone presents with bilateral disc edema and BP is normal

Answer 3

Urgent (within a few days) MRI indicated to r/o intracranial mass. If the MRI is normal, a lumbar puncture is indicated to measure the opening pressure and to analyze the composition of the cerebrospinal fluid to r/o infectious/inflammatory causes of bilateral disc edema

The MRI will be “normal” in IIH, but the optic nerves will look tortuous

Question 4

Symptoms of pseudotumor cerebri

Answer 4

HAs, TVOS, tinnitus, CN 6 palsy

Question 5

Signs of pseudotumor

Answer 5

Disc edema, increased rim tissue thickness and RNFL on OCT, HVF shows enlarged blind spot

Question 6

What needs looked at on a lumbar puncture for pseudotumor

Answer 6

Opening pressure

Analysis of CSF

Question 7

What is papilledema

Answer 7

Bilateral disc edema due to elevated intracranial pressure. Technically a patient cannot be Dxed with this until a lumbar puncture is performed and the CSF pressure is noted as elevated

Question 8

Presence of SVP

Answer 8

Helpful to r/o suspected papilledema when the optic nerves are difficult to assess; if an SVP is present, the patient does NOT have disc edema. Remember that appx 10-20% of healthy people do NOT have SVP; thus, the lack of an SVP in patients with papilledema is not helpful, unless an SVP has been previously documented

Question 9

Systemic meds that can contribute to papilledema

Answer 9

CANT

• contraceptives
• vitamin A and accutane
• Naladixic acid
• Tetras

Question 10

What is considered increased ICP

Answer 10

> 200mm water (or >250mm in patients who are obese)

Convert to centimeters and its similar to IOP

Question 11

Papillitis secondary to optic neuritis

Answer 11

Unilateral disc edema. Recall that 90% of patietns with optic neuritis present with pain on EOMs

Question 12

Things that can cause pseudopapilledema

Answer 12

Small crowded disc
Tilted disc
Disc drusen

Question 13

Optic disc drusen

Answer 13

Do FAF
Can mimic GLC on RNFL but small cup

Compression of the ganglion cell fibers and obstruct the axoplasmic flow, however patients will not present with an elevated opening pressure on lumbar puncture

Question 14

Arteritic AAION

Answer 14

Occlusion of the SPCA due to GCA. Presents with unilateral disc edema and decreased vision. Most commonly in patients >55 with systemic symptoms of GCA
-temporal HA, neck pain, jaw claudication, scalp tenderness, anorexia

Question 15

What is graves

Answer 15

An AI disorder characterized by TSH receptor autoAbs abasing the EOMs and orbital tissue, resulting in significant inflammation and thickening of the EOMs

• compression of the ON with resulting disc edema occurs in 5% of patients in the late stage of the disease
• present with proptosis and enlarged EOMs on MRI scan

Question 16

Papilledema due to meningitis

Answer 16

Will be very sick and complain of severe neck pain

Question 17

Disc drusen

Answer 17

Composed of hyaline bodies an can be hereditary. Disc drusen tend to be buried when patients are young, but they gradually move anterior and become more superficial with age. They are typically bilateral and are commonly diagnosed with B scan; will often appear hyperreflective, even with a decrease in gain. AutoFl imagining and an OCT raster scan through the optic nerve may also aim in imaging

Question 18

First line treatment of IIH

Answer 18

Weight loss (6% reduction)
CAIs
Lasix

If those dont work, surgical intervention can be considered:
Optic nerve sheath decompression
Shunts

Question 19

Diamox side effects

Answer 19

Aplastic anemia (bleeds, pale, and tired, gets infection easily)
Metallic acidosis 
Metallic taste
Depression
Gastric upset 
Parenthesis 
Transient myopia 
Abnormal kidney/live function 
Skin rash
Thrombocytopenia, agranulocytosis

Question 20

What is a common secondary problem from IIH

Answer 20

CN 6 palsy