An overview

1. PAPILLOEDEMA

2. Definition
▪ Passive hydrostatic non inflammatory swelling of
optic nerve head secondary to raised intracranial
pressure.
▪ Usually bilateral ; may be unilateral.
▪ Optic disc swelling in the absence of raised
intracranial pressure is referred to as optic disc edema.

3. Pathophysiology
Disturbance in axoplasmic flow causing stasis
swelling of axons and leakage.
Increased intracranial pressure(ICT) is
along subarachnoid space with optic nerve sheath
acting as a tourniquet.
Increased ICT leads to increased optic nerve
tissue pressure which alters pressure gradient
resulting in stasis

6. Theories of Genesis
Mechanical Theory
Ischemic Theory
In most cases combined mechanism operates.

7. Causes(Bilateral)
Space occupying lesions.
Blockage of CSF flow.
Reduction in CSF resorption.
Increased CSF production.
Idiopathic Intracranial Hypertension.
Focal or diffuse cerebral edema.
Reduction in size of Cranial Vault.
Vitamin A toxicity.

8. Causes(Unilateral)
Foster kennedy syndrome
Previous unilateral optic atrophy. Posterior
fossa tumor.
Brain abcess.
Subarachnoid haemorrhage.
Optochiasmatic choroiditis.

9. Symptoms(Ocular)
Visual Acuity
Transient obscuration of vision.
Central vision affected late.
Horizontal Diplopia

10. Symptoms(General)
Headache more in the morning, intensifies
head movement, coughing or straining.
Projectile vomiting.
Loss of consciousness/ generalized motor
rigidity.

11. Signs(Mechanical)
Elevation of the optic disc.
Blurring of the optic disc margin.
Filling in of the physiological cup.
Edema of the peripapillary nerve fiber layer.
Retinal or choroidal folds(Paton’s lines)
Macular fan.

12. Signs(Vascular)
Hyperemia of the optic disc.
Vascular congestion.
Peripapillary haemorrhage.
Exudates in the disc or peripapillary area.
Nerve fiber layer infarcts.

13. Grading of Papilledema (according to severity
and its chronicity)

14. Early Papilledema
Disc elevation.
Venous distention and
tortuosity.
Obscuration of the normal disc margin and
overlying
retinal vessels.
Absence of spontaneous venous pulsations

15. Established Papilledema
Marked elevation of nerve head with blurring of
margins.
Engorged tortous venules. Peripapillary
hemorrhages.
Cotton wool spots.
Hard exudates over the disc and macular area.

16. Chronic Papilledema(Classical “Champagne cork
appears of disc)
disc hyperemia decreases and disc
appears pale in color.
Optociliary shunts and drusen like deposits
be present on the disc.
High water mark.

17. Atropic Papilledema
Onset of optic disc pallor (secondary optic
atrophy) .
Decrease in disc haemorrhage.
Narrowing of blood vessels
and their ensheating.
Optic disc appears dirty white and blurred due
glial
reaction.

18. Papilledema Grading System (Frisen Scale)

19. Grade 0
Mild nasal NFL elevation.
Rare obscuration of a portion
of major vessel
(usually at superior pole)

20. Grade 1 (Very early Papilledema)
Obscuration of nasal border of disc
Normal temporal disc margin

21. Grade 2 (Early papilledema)
Obscuration of all the disc borders
Elevation of nasal border
No major vessel obscuration

22. Grade 3 (Moderate papilledema)
Obscuration of all borders
Increased diameter of optic
nerve head
Obscuration of segment of major blood
as they pass disc margin.

23. Grade 4 (Marked papilledema)
Elevation of entire nerve head
Obscuration of all the borders
A segment of major vessel obscured on the disc

24. Grade 5 (Severe papilledema)
Anterior extension of optic nerve head
Total obscuration of vessel on disc surface
Obliteration of optic cup

25. Histopathological Findings
Acute disc edema
Accumulation of extracellular fluid in and
to retinal lamina cribrosa, with enlargement of
subarachnoid space with stretching.
Engorgement of axons occurs in prelaminar
portion.

26. Sensory retinal changes
- Displacement of retina away
from optic disc.
- Buckling of the outer layers of retina.
- Displacement of rods and cones away from their
anchor near Bruch’s membrane.
- Serious RD in peripapillary area

27. Electron microscopy of axons
- Axonal swelling and accumulation of
mitochondria.
- Mitochondrial swelling and disruption.
- Disruption of fascicles of the microtubules.

28. Chronic disc edema
Degenerative and fibrotic changes in both
anterograde and retrograde manner. (hence
atrophy may occur anywhere from retinal nerve
fiber layer to optic nerve)

29. Visual field changes
Enlargement of blind spot.
Earliest loss of visual field commonly involves
inferior nasal quadrant.
Peripheral concentric constriction.

30. Relative scotoma (first to green and red).
Complete blindness.
In all cases visual field changes should be
monitored carefully and decompression to be done
before peripheral constriction sets in.

31. Differential diagnosis of
Papilledema
 Papillitis.
 Pseudopapilledema.
- Drusen of optic disc.
- High Hypermetropia (crowded
nerve fibers at disc). - AION.
 Optic neuritits.
 Tilted optic disc.
 Hypoplastic disc.
 Myelinated nerve fibers.

32. Papillitis

33. Pseudopapilledema
- Drusen of Optic disc

34. Pseudopapilledema - Hyperopic disc

35. Tilted optic disc

36. Hypoplastic disc

37. Myelinated nerve fibers

39. Investigations
History and physical examination including
pressure measurement.
Ophthalmic examination - In addition to fundus
examination, assessment of visual acuity, pupillary
examination, ocular motility & alignment, and
visual fields.
MRI with or without contrast is the best
investigation of choice.

40. CT Scan
To rule out
- Intracranial lesions.
- Obstructive hydrocephalus.
Can detect
- Subarachnoid, epidural
& subdural hemorrhages. - Acute infarctions.
- Cerebral edema.
Contraindication for MRI

41. Lumbar puncture
Therapeutic procedure - Pseudotumor cerebri
CSF for microbial and infectious studies.
Diagnostic
- Recording opening pressure.

42. Fundus Fluoroscence Angiography(FFA)
Early Phase
disc capillary dilation
Dye leakage spots Microaneurysm over the disc
Late Phase
Leakage of dye beyond disc margin Pooling of dye
around the disc

43. TREATMENT:
Treatment directed at underlying cause.
Timely intervention has a remarkable effect on
prognosis.
(unless nerve is irreversibly damaged)
Vision recovery is faster then subsidence of
fundus features.

44.  Brain Tumor
- Craniotomy to remove tumor.
 Resolution of papilledema within 6-8weeks.

45. Pseudotumor Cerebri
- Medical
Acetazolamide
Oral Glycerol
Corticosteroids
Weight reduction
- Surgical
Repeated Lumbar puncture Decompression
Shunting procedure
Resolution of papilledema within 2-3weeks of
procedure.

46. Papilledema in PIH
General – bed rest.
Control of BP.
Control of edema – Diuretic, Hypertonic glucose.
Non responders – Termination of pregnancy.

47. Surgical Decompression
Indications
Failure of Medical treatment - Marked disc
swelling(>5D) - Engorged veins
- Extensive hemorrhages
- Early exudate spots
- Progressive headache
Progressive optic neuropathy (early field
constriction)
Direct Fenestration of optic nerve sheath.

48. THERAPEUTIC SUCCESS :
Relief of headache.
Transient visual obscuration decreased.
Stability/ improvement of field defects.

49. Case report on papilloedema due to IIH
A 20 year old female patient came with chief complaint of
headache and blurring of vision since 3 days.She has been
Tab.Brutaflam 4mg.BD Tab.MAHAGABA M75OD since 1 week
generalized myalgia.On examination BCVA RE-6/24,LE-
6/18.Pupils-Grade 1 RAPD BE present.Colour vision is
normal.Anterior segment is within normal limits.Fundus
examination with slit lamp indirect ophthalmoscopy with 90D
revealed bilateral grade 4 optic disc edema.General physical
examination is normal.Routine investigations were advised and
patient was referred to neurophysician.Hb is 10.2mg/dL.CT
is normal with bilateral basal ganglia calcifications.Patient
for CSF analysis.She was diagnosed as IIH and treated with
Tab.Diamox 250mg.BD,Tab.Lasilactone 50/20mg.OD and Oral
Glycerol 20ml.TID.At one month follow up BCVA RE-6/9,LE-
6/6.Pupils are round reacting to light.Fundus showed resolving
papilloedema,hard exudates in macula in a star pattern
Conclusion:NSAIDs and GABA Agonists may cause IIH.

50. THANQ!!!