Disc oedema is a common entity in ophthalmology. Different causes and differential diagnosis are described in the ppt. Pathogenesis, clinical features,signs, symptoms and treatment options are described. Papilloedema should be differntiated from optic neuritis. Papilloedema has different stages in its clinical courses. Different stages has its separate appearance. Different clinical tests are done to see the progress of the disease.

1. Papilledema
Dr. Sayantan Manna, DNB resident, SEFRC
Moderated by Dr. Soumava Mandal, Consultant & Head,
VR services, SEFRC

3. Papilledema = edema of the optic disc due to raised intracranial pressure

4. Pathogenesis of papilledema
• Subarachnoid and subdural spaces around the optic nerve are continuous with that
around the brain
• Rise in ICT  subarachnoid space swells
• Purely hydrostatic, non-inflammatory, phenomenon

6. Raised ICT
Compression of the central retinal vein in the subarachnoid and subdural space

7. Raised ICT
Compression of CRV
Stasis of axoplasmic transport
Swelling of optic disc + mechanical changes

8. Etiology

9. • When the skull is too small for the brain (e.g., craniosynostosis)

10. • When the brain volume becomes too large for the skull, i.e., a IC-SOL (e.g., tumour,
haemorrhage, abscess, aneurysm), or brain edema (e.g., post-trauma)

11. • When there is obstruction in CSF flow (e.g., a cyst obstructing the foramen of Monro)

12. • Increased production of CSF (e.g., choroid plexus papilloma)

13. • Reduced absorption of CSF (e.g., meningitis, cerebral venous thrombosis)

14. • Malignant hypertension

15. Symptoms

16. • May be asymptomatic
• Headache – worse in recumbent position (+/- N/V)
• Pulsatile tinnitus
Visual symptoms
• Transient visual obscurations (episodes of unilateral or bilateral vision loss lasting
seconds) - described as grayouts / whiteouts / blackouts of vision, often
occurring with orthostatic changes
• Diplopia (CN 6)
• Peripheral visual field loss, may progress to involve central vision if untreated
• A hyperopic shift may occur secondary to the posterior flattening of the globe (causing
axial length shortening).

17. Signs

18. Physical examination
• Do not miss HTN !
Ophthalmic examination
“PAPILLEDEMA”

19. Mechanical findings
- Blurring of disc margins
- Hyperaemia of disc
- Obliteration of optic cup
- Swelling and elevation of optic disc
- Retinal folds (Paton’s lines)
- Loss of reddish hue
- Opacification of retina
- Ischemia, infarction and direct pressure-
induced axonal damage
- Reactionary organisation (gliosis)
- Secondary optic atrophy (post-
papilledema optic atrophy)
Vascular findings
- Dilated and tortuous vessels
- Absent spontaneous venous pulsations
- Red streaks (prominent arterioles)
- Punctate and flame-shaped haemorrhages
- Cotton wool spots (retinal micro-infarcts)
- Incomplete macular star (fans towards
disc)

20. Grade 1 – halo with temporal gap.

21. Grade 2 – circumferential halo.

22. Grade 3 – loss of major vessels as they leave the disc.

23. Grade 4 – loss of major vessels on the disc.

24. Grade 5 – partial or total obscuration of all vessels on the disc.

25. Chronic papilledema
• Disc paler
• Optociliary shunts (retinochoroidal
collaterals)

27. Foster-Kennedy Syndrome

28. • presents with optic atrophy in one eye and papilledema in the contralateral eye.
• Etiology – compressive ipsilateral optic atrophy due to an intracranial mass (e.g., anterior
cranial fossa meningioma, mass on frontal lobe, olfactory groove, sphenoid wing.
Elevated ICT due to IC-SOL  contralateral optic nerve edema.

29. Diagnosis

30. • Clinical diagnosis (fundoscopy)
• SD-OCT (RNFL scan and macular scan)
• Stereo disc images
• Automated perimetry
• Fluorescein angiography
• Neuroimaging (CT, CT venogram, MRI,
MRV)
• Lumbar puncture

31. Management

32. • Principles of treatment :
- treat underlying cause
- save vision
- symptomatic relief
• Optic nerve sheath decompression
• Dural venous shunting (ventriculo-peritoneal / lumbo-peritoneal shunting)

33. Differential diagnoses
• anomalous optic discs: buried drusen, tilted disc, hypoplastic discs
• diabetic papillopathy
• hypertensive papillopathy
• obstructive sleep apnea
• Intraocular or peri-ocular inflammation: posterior scleritis, perineuritis, uveitis with
associated optic disc edema ( e.g. sarcoidosis, toxoplasmosis, and VKH), neuro-retinitis
• compressive optic neuropathy (optic nerve sheath meningioma)
• optic neuritis
• thyroid ophthalmopathy
• Central Retinal Vein Occlusion
• Non-arteritic ischemic optic neuropathy
• Infiltrative optic neuropathy and tumors (lymphoma, leukemia)

34. Take home message
• Papilledema may be asymptomatic.
• Exclude differential diagnoses : h/o SOLs, HTN, vasculitis ( fever, rash, joint aches,
bowel problems), meningitis (fever, neck stiffness), cerebral venous thrombosis (personal
or family h/o hypercoaguable states, smoking, OCPs), and medications that might
precipitate high ICP (tetracyclines, vitamin A and derivatives, lithium, steroids or steroid
withdrawal).
• Rule in / rule out risk factors associated with IIH : recent weight gain, thyroid disease,
anemia, PCOS, OSA, etc.

35. Thank you!