Dd of disc edema

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Dd of disc edema

  1. 1. Guide: Dr Anupama Karanth Presenter: Dr Madhurima
  2. 2. Causes of pseudo disc edema • Optic nerve head drusen : disc elevation • Medullated nerve fibres : blurred margins • Morning glory syndrome: elevated disc • Tilted disc: blurred margins • Small hyperopic disc: hyperemic disc • Optic disc dysplasia • Bergmeister’s papilla
  3. 3. True disc edema Pseudo disc edema Disc color Hyperemic Yellow Nerve fibre layer Opacified Transparent Large vessels Normal Anomalous- trifurcation, spoke like Small vessels Telangiectatic Normal
  4. 4. True disc edema Pseudo disc edema Spontaneous venous pulsation Absent Present in 80% Hyaline bodies Absent May be present Optic cup Normal initially, filled Small or absent Nerve fibre layer hemorrhages Frequent Absent Fluorescein angiography Dye leakage at disc No leakage/ late staining
  5. 5. • Hyaline like calcific material in the substance of optic nerve head, autofluorescence, trifurcation of vessels • Causes disc edema if buried, diagnosed by B Scan
  6. 6. • Obliquely entering nerve, inferonasal chorioretinal thinning • Bitemporal hemianopia Blurred margin Nasally entering vessels
  7. 7. Large disc with funnel shaped excavation surrounded by chorioretinal atrophy, with central tuft of white material Spoke like vessels Elevated disc Hyperemic
  8. 8. Presence of feathery grey streaks may simulate disc edema, but distal fan shaped appearance aids recognition Feathery streaks Margins blurred, disc elevated
  9. 9. Mechanical signs  Elevation of the optic disc (3D=1mm)  Blurring of the optic disc margins  Filling in of optic cup  Edema of peripapillary nerve fiber  Retinal or choroidal folds Vascular signs  Hyperemia of disc  Venous congestion  Peripapillary hemorrhages  Exudates in disc or peripapillary area  Nerve fiber layer infarcts
  10. 10. Diagnosis is done best by binocular stereoscopic viewing using a high convex lens, with magnification especially to detect the subtle changes in disc elevation.
  11. 11. Once true disc edema is established, papilledema (due to raised ICT) has to be distinguished from other optic neuropathies which can be of varied etiology The main difference is visual acuity and optic nerve function which is normal in papilledema and disturbed in papillitis.
  12. 12. Papilledema is a bilateral, passive, non inflammatory swelling of the optic disc secondary to raised intracranial tension Stages of papilledema: • Early papilledema • Established papilledema • Chronic papilledema • Atrophic papilledema
  13. 13.  Difficult to diagnose  Disc hyperemia  Blurring of peripapillary retinal nerve fibre layer  Blurring of the disc margins  Disc elevation  Dilatation of retinal veins  Hemorrhages on disc margins  Absence of spontaneous retinal vein pulsations (normal in 20% population)
  14. 14. Established papilledema: obscuration of all borders, disc elevated, cup filled, blood vessels obscured on the surface, peripapillary hemorrhages. Chronic papilledema: cup is obliterated, hard exudates occur within the nerve head Post papilledema atrophy: post neuritic type, arterioles are narrowed or sheathed, optic disc appears dirty gray and blurred
  15. 15. Early papilledema Chronic papilledema Atrophic papilledema Established papilledema Yanoff and Duker
  16. 16. Papilledema Papillitis Laterality Bilateral Unilateral Symptoms Transient loss of vision Sudden diminution of vision No pain Pain on extra ocular movement Pupillary reaction Normal RAPD Media Clear Posterior vitreous cells
  17. 17. Papilledema Papillitis Disc elevation 2-6 D Does not exceed 2-3D Venous engorgement, peripapillary hemorrhages More frequent Less frequent
  18. 18. Papilledema Check BP Stage IV hypertensive retinopathy Bilateral disc edema, other signs of raised ICT
  19. 19. Malignant hypertension Young individuals Severe attenuation of arterioles Neuroretinopathy, presence of disc edema, multiple cotton wool patches, hard exudates, macular star Grave prognosis, associated with renal insufficiency
  20. 20. Neuro imaging CT scan Abnormal 1. Space occupying lesions Tumors, abscesses, hemorrhages, infarcts, AV malformations 2. Trauma 3. Inflammatory Sarcoid, tuberculoma 4. Extra cranial lesions Idiopathic intracranial hypertension •Cerebral venous thrombosis •Endocrinal abnormalities •Drug overdose/ withdrawal • SLE •Idiopathic Normal Normal BP
  21. 21. Signs and symptoms of raised ICT Normal neurologic examination except VI nerve palsy Elevated CSF opening pressure with normal spinal fluid formula Neuroimaging demonstrating normal or small ventricles and excluding a mass lesion
  22. 22. Atypical demographic profile (male patient, non obese patient) Cranial nerve palsies other than 6th nerve palsy Abnormal CSF profile Alteration in level of consciousness Focal neurologic deficit Rapid progression of symptoms
  23. 23. Diagnosis is made by MR venogram Right transverse sinus thrombosis
  24. 24. Papilledema Check BP Hypertensive retinopathy Neuro imaging Abnormal Normal Intracranial space occupying lesions Lumbar puncture Opening pressure high Idiopathic intracranial hypertension Normal opening pressure Abnormal spinal fluid analysis Meningitis
  25. 25. Anterior optic neuropathy • Inflammatory optic neuropathy • Ischemic optic neuropathy • Compressive optic neuropathy • Toxic and hereditary optic neuropathy • Infiltrative optic neuropathy Intraocular causes • CRVO, posterior uveitis, posterior scleritis, hypotony Neuro retinitis/ ODEMS
  26. 26. Optic neuropathies should be considered under two circumstances Visual loss associated with anomalous, swollen or pale disc Fundus is normal, but acuity, color vision, field abnormalities are accompanied by an afferent pupil defect
  27. 27. Additional features  Multiple sclerosis  Pain and tenderness  Central and centrocecal scotoma  Contrast sensitivity  MRI-periventricular plaques It is defined as inflammation of the optic nerve head associated with decrease in visual acuity or visual field loss.
  28. 28. Typical optic neuritis  Young adult  Usually associated with multiple sclerosis  Vision starts to improve by 2-3 weeks Atypical optic neuritis  Marked disc swelling  Vitritis  Progression of visual loss after 1 week  Lack of partial recovery within 4 weeks of onset  Persistent pain
  29. 29.  Typical optic neuritis  MRI is the only required investigation in typical optic neuritis  Atypical optic neuritis  MRI  CSF cytology  Syphilis- MHATP  Lyme titre  Sarcoid- CXR, ACE  Lupus-ANA  Nutritional-B12
  30. 30.  Sudden loss of vision  Interference with blood supply of the posterior ciliary artery to the anterior part of the optic nerve  Can be arteritic or non arteritic  Arteritic is associated with Giant cell arteritis. It constitutes an Ophthalmic emergency  Non arteritic- no overt symptoms, associated with hypertension, diabetes, hypercholesterolemia and shock.
  31. 31. Arteritic Non arteritic Sex predilection Females>males Females=males Age >60 years 40-60 years Visual loss Severe Moderate, on awakening Associated symptoms Pain, jaw claudication, headache, bright light amarousis No pain Second eye involvement Within days or weeks(70%) In months (30-40%) Disc Pallor> hyperemia, chalky white Hyperemic > pallor Sectoral edema ESR >90mm/hr <40mm/hr
  32. 32. Arteritic Non arteritic Other signs of ocular ischemia May be present Not present Anatomic predisposition None Small crowded disc Late optic atrophy Can have cupping Simple pallor Response to steroids Vision-sometimes Systemically-definite None Fluorescein angiography Choroidal filling defects Normal, can have delayed optic nerve head filling
  33. 33. Chalky white disc Disc edema Arteritic ischemic optic neuropathy
  34. 34. Sectoral edema Disc filling defects
  35. 35. Disc appearance  Disc swelling  Opticociliary shunts  Foster Kennedy syndrome Additional features  Eg: optic nerve gliomas • Glioblastomas • Meningiomas • Aneurysms  Slowly progressive visual loss  Proptosis, gaze evoked amarousis
  36. 36. Optic nerve glioma
  37. 37. Disc appearance  Disc hyperemia  Obscuration of disc margins  Dilated capillaries on disc surface that may extend into surrounding retina (telangiectatic microaneurysms), Additional features  Swelling of NFL layer and dilatation  Tortuosity of posterior pole vasculature  Maternally inherited mt DNA mutations  Males, 15-35 years  Subacute painless severe loss of vision in one eye, followed by the other
  38. 38.  Posterior pole vasculature- tortuous  Hyperemic disc  Telangiectatic microaneurysms
  39. 39. Optic neuropathy due to methanol poisoning is different from others as it causes sudden visual loss and disc edema. Disc edema is indistinguishable from papilledema Other symptoms are headache, dyspnoea, vomiting, abdominal pain and bilateral visual blurring.
  40. 40.  Leber’s stellate neuroretinitis  No risk of MS  Cat scratch disease, syphilis, Lyme disease, HIV  Look for systemic cause  Presents like ON  Good prognosis Macular star
  41. 41. Disc appearance  Hyperemic edematous disc  Neovascularization  Glaucomatous changes Additional features  Retinal hemorrhages in all four quadrants  Dilated, tortuous veins in all four quadrants  Macular edema  Decreased acuity  RAPD
  42. 42. Papillitis Compressive optic neuropathy Ischemic optic neuropathy Infiltrative optic neuropathy CRVO and venous stasis retinopathy Optic disc vasculitis
  43. 43. Increased intracranial tension Hypertensive retinopathy Diabetic papillopathy Leber Hereditary optic neuropathy Toxic optic neuropathy Advanced Graves disease Cavernous sinus thrombosis Carotid cavernous fistula
  44. 44. Pediatric papilledema Infrequent in infants In children, most common cause is neoplasms Craniosynostosis Child abuse, shaken baby syndrome, battered baby syndrome-look for retinal hemorrhages. Papilledema indicates sub dural hematoma
  45. 45. Usually bilateral, disc swelling more common More aggressive treatment Immune mediated • Usually bilateral, post infectious • Acute demyelinating encephalopathy • Good prognosis Idiopathic • Demyelination • 10-50% eventually develop MS
  46. 46. 1. Visual fields • Papilledema, perineuritis: enlarged blind spot, nasal arcuate scotomas • AION: altitudinal defects • Optic neuritis, toxic optic neuropathies: central scotoma, centrocecal scotoma • Tilted disc syndrome: bitemporal hemianopia which does not respect the vertical midline
  47. 47. • Papilledema: disc capillary dilatation, dye leakage and microaneurysm formation • AAION: delayed filling in choroidal phase • NAAION: delayed disc filling, segmental disc fluorescence (surface telangiectasias) • ODEMS: no leakage at macula • Hypertensive retinopathy: leakage from small vessels at macula
  48. 48. CT scan: tumors, hematomas, abscesses causing papilledema, compressive optic neuropathies MRI: • MS-periventricular plaques • IIH: empty sella MR Angiography- cerebral venous thrombosis, Aretero venous malformations
  49. 49. Polycythemia: CRVO, IIH Hypercholesterolemia – NAION ESR: AION NMO Ig: Devic’s disease Blood sugars: diabetic papillopathy ANA, Lyme titre, FTA Abs-atypical optic neuritis
  50. 50. Opening pressure>250mm H2O: raised ICT MS: oligoclonal bands Decreased glucose, increased proteins: meningitis 6. Ultrasound  Optic disc drusen- B Scan
  51. 51. 41 year old man, referred for blurred disc margins History of swollen groin lymph nodes 1 month back, no other history Headache, eye pain Vision BE 20/20, color vision OU normal, LE RAPD IOP RE 12mm Hg, LE 18mm Hg “Neurosyphilis Presenting as Asymptomatic Optic Perineuritis,” Case Reports in Ophthalmological Medicine, vol. 2012, Article ID 621872, 4 pages, 2012. doi:10.1155/2012/621872
  52. 52. “Neurosyphilis Presenting as Asymptomatic Optic Perineuritis,” Case Reports in Ophthalmological Medicine, vol. 2012, Article ID 621872, 4 pages, 2012. doi:10.1155/2012/621872
  53. 53.  Visual fields: enlarged blind spot  MRI orbit: increased optic nerve sheath fluid, especially behind the globe  RPR and FTA Abs: reactive “Neurosyphilis Presenting as Asymptomatic Optic Perineuritis,” Case Reports in Ophthalmological Medicine, vol. 2012, Article ID 621872, 4 pages, 2012. doi:10.1155/2012/621872
  54. 54. A 9 year old boy, intermittent headache and bouts of abdominal pain since 3 months, no h/o recent infections, systemic medications General examination was unremarkable Vision BE 6/6, N6, color vision BE within normal limits, pupils and visual fields were normal Bilateral Optic Disc Swelling as the Presenting Sign of Pheochromocytoma in a Child Medscape J Med. 2008;10(7):176 © 2008 Medscape
  55. 55. Bilateral Optic Disc Swelling as the Presenting Sign of Pheochromocytoma in a Child Medscape J Med. 2008;10(7):176 © 2008 Medscape
  56. 56. BP-220/140mm Hg On further questioning, frequent micturition and excessive sweating was reported Abdominal USG and MRI revealed a right sided suprarenal mass Increased urine catecholamines Diagnosis: Pheochromocytoma Bilateral Optic Disc Swelling as the Presenting Sign of Pheochromocytoma in a Child Medscape J Med. 2008;10(7):176 © 2008 Medscape
  57. 57. Thank you

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