Papilledema Flashcards
What is the first thing you do if someone has bilateral disc edema in your office
Check BP immediately in order to r/o malignant HTN
Malignant HTN
Defined as dangerously high BP >220mmHg systolic and/or >120mmHg diastolic. The patient must be hospitalized immediately due to the high risk of stroke
If someone presents with bilateral disc edema and BP is normal
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
Symptoms of pseudotumor cerebri
HAs, TVOS, tinnitus, CN 6 palsy
Signs of pseudotumor
Disc edema, increased rim tissue thickness and RNFL on OCT, HVF shows enlarged blind spot
What needs looked at on a lumbar puncture for pseudotumor
Opening pressure
Analysis of CSF
What is papilledema
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
Presence of SVP
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
Systemic meds that can contribute to papilledema
CANT
- contraceptives
- vitamin A and accutane
- Naladixic acid
- Tetras
What is considered increased ICP
> 200mm water (or >250mm in patients who are obese)
Convert to centimeters and its similar to IOP
Papillitis secondary to optic neuritis
Unilateral disc edema. Recall that 90% of patietns with optic neuritis present with pain on EOMs
Things that can cause pseudopapilledema
Small crowded disc
Tilted disc
Disc drusen
Optic disc drusen
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
Arteritic AAION
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
What is graves
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
Papilledema due to meningitis
Will be very sick and complain of severe neck pain
Disc drusen
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
First line treatment of IIH
Weight loss (6% reduction)
CAIs
Lasix
If those dont work, surgical intervention can be considered:
Optic nerve sheath decompression
Shunts
Diamox side effects
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
What is a common secondary problem from IIH
CN 6 palsy
