A detailed study of various cases of disc oedema and their approach.

1. Approach to a case of disc
oedema
Dr. Sourav Santra
Department Of Vitreo-Retina

2. Confirm
 We have to first make sure whether disc
oedema is true or not!!
True Pseudo

3. Optic nerve head drusen Bergmeister’s papilla
Myelinated nerve fibres
Causes of pseudo-disc oedema
Morning glory syndrome

4. True disc edema Pseudo disc edema
Disc color Hyperemic Yellow
Nerve fibre layer Opacification Transparent
Optic disc margins Blurry Sharp
Spontaneous venous
pulsation (SVP)
Absent Present
Optic cup Filled Small or absent
Nerve fibre layer
hemorrhages
Frequent Absent
Fluorescein angiography Dye leakage at disc No leakage/ late staining

5. Examination in a patient with optic
disc swelling
 RAPD +/-
 Examination of fellow eye
 Visual acuity
 Colour vision
 Contrast sensitivity

6. Examination in a patient with optic
disc swelling
 Visual fields
 Colour of the disc & any abnormal
vasculature.
 Spontaneous venous pulsation(SVP) +/-
 RNFL opacification +/-

7. Causes of disc oedema
Inflammatory Optic neuritis
Uveitis
Granulomatous TB
Sarcoidosis
Infiltrative Leukemia
Lymphoma
Vascular AION
CRVO
Diabetic papillopathy
Tumours Optic Nerve (meningioma, glioma)
Hereditary LHON
Ocular hypotony

8. Case 1
 36 /F
 Occasional headache for last 3 months
 Undergoing infertility t/t- on hormonal drugs
 Recent weight gain
 BCVA 6/6 B/E
 Colour vision normal B/E
 No RAPD
 BP- 127/90

11.  Routine blood tests- normal
 MRI was normal
 MRV showed no venous sinus thrombosis.
 CSF study was normal.
 CSF pressure high.

12. Peripheral visual fields depressed in
both eye

13.  Provisional diagnosis- Idiopathic intracranial
hypertension (IIH).
 Patient started on tablet acetazolamide.
 Referred to gynaecologist.

14. Follow up after 1 month

15. Case 2
 38/F
 Sudden DOV for 10 days R/E
 Painful eye movement R/E.
 BCVA 6/36 R/E and 6/6 L/E
 RAPD + R/E
 Colour vision severely impaired R/E
 BP- 110/70

16. Fundus picture

17. MRI : Increased contrast sensitivity in
right optic nerve

18. Automated perimetry

19.  Routine tests - Normal
 Provisional diagnosis: Optic neuritis R/E
 Treatment: IVMP 1gm daily for 3 days
 Oral prednisolone(1mg/kg/day) for 11 days
 Tapered over 4 days

20. Before
Follow up after 2 weeks

21. Papilledema Papillitis
Laterality Bilateral Unilateral
Symptoms Transient loss of vision Sudden diminution of
vision
Extra ocular movement No pain Painful
Pupillary reaction Normal RAPD
Media Clear Posterior vitreous cells

22. Case 3
 29/F
 Blurring of vision R/E
 T/t with steroids for choroiditis(e/w)
 BCVA 6/9 R/E and 6/6 L/E
 BP-130/80 mm of Hg
 Occasional anterior vitreous cells

23. Fundus picture

24. R 0:28.0

25. R 1:41.0 45º

26. On 1st follow up
 Mantoux test(5 TU)- 21 mm
 Quantiferon TB gold test- Positive
 VDRL negative
 Serum ACE - Normal
 CXR- Normal
 Patient started on ATT

27.  Patient followed up after 2 months with BCVA
6/6 in R/E.

28. Case 4
 54/F
 Diabetic-Controlled
 DOV for last 6 days R/E
 BCVA 6/36 R/E and 6/9 in L/E
 BP- 130/84

29. Fundus picture

30. Right eye visual field shows inferior
hemifield defect

31.  Routine haemogram normal
 Hba1c- 6.4%
 Other tests: Normal
 Provisional diagnosis: NAION R/E
 Patient was started on tablet
methylcobalamin and e/d brimonidine

32. Previous BCVA 6/36 After 1 month BCVA 6/9

33. Arteritic Non arteritic
Sex predilection Females>males Females=males
Age >60 years 40-60 years
Visual loss Severe Moderate, on
awakening
Associated symptoms Pain
Headache
Jaw claudication
No pain
Anatomic predisposition None Small crowded
disc
ESR >60mm/hr <40mm/hr

34. Case 5
 35/F
 Painless DOV for last 10 days L/E
 H/O fever 2 weeks back.
 BCVA – 6/6 right eye and 6/60 left eye
 BP- 110/80 mm of Hg
 RAPD positive L/E
 Colour vision markedly reduced L/E

36.  Provisional diagnosis: Neuroretinitis L/E
 The patient was empirically started on tablet
ciprofloxacin(500 mg BD for 10 days).
 Follow up after 14 days, all routine tests were
normal.
 BCVA L/E improved to 6/9 after 2weeks.

37. Case 6
 20/F
 Sudden Blurring of vision B/E for last 3 days
 BCVA 6/9 both eye
 No h/o any previous ocular/systemic diseases

38. Fundus picture

39.  BP- 190/120
 Routine haemogram normal
 Mantoux test (5TU) negative
 HIV, VDRL, HBsAg negative
 Urgent control of BP
 To consult physician

40. Follow up after 2 months

41. Optic Disc Oedema
Measure BP
High BP Normal BP
Treat
hypertension Neuroimaging (MRI, CT, MRV)
Mass lesions/
Venous sinus
thrombosis
Refer
Normal
Lumbar puncture + CSF study
CSF abnormal Normal
opening
pressure
Raised CSF opening pressure
Treat underlying condition
Rule out pseudopapilledema
and other causes
IIH