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. 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. • Hyaline like calcific material in the substance of optic nerve head,
autofluorescence, trifurcation of vessels
• Causes disc edema if buried, diagnosed by B Scan
7. Large disc with funnel shaped excavation surrounded
by chorioretinal atrophy, with central tuft of white
material
Spoke like vessels
Elevated disc
Hyperemic
8. Presence of feathery grey streaks may simulate disc edema,
but distal fan shaped appearance aids recognition
Feathery streaks
Margins
blurred, disc
elevated
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. 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. 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. 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. 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. 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
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
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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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
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
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. 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. 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
45. 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
46. 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
47. 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
48. • 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
52. 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
53. “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. 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