case presentation of a patient with disc edema on routine eye examination

1. OPTIC DISC SWELLING
Dr Abdul Munim Khan
Associate Professor & HOD
Ophthalmology
Dr Khawaja Abdul Hamid
Assistant Professor Ophthalmology
Mohtarma Benazir Bhutto Shaheed
Medical College Mirpur AJK

2. CASE PRESENTATION
Patient xyz, 35 year old female, housewife, married with
three children
Resident of Khaiaban-e-Sir Syed, Rawalpindi
PRESENTING COMPLAINT
Severe headache …………..for the last four months

3. The headache occurred mostly early in the morning
Severe and generalized in nature.
It was Aggravated by coughing.
Relived with OTC analgesics
It was associated with vomiting, which was episodic
and projectile and used to give transient relief to the
headache
There was Progressive worsening in severity of
headache
Decrease in response to analgesics occurred with time.

4.  The patient also complained of posture related
vague, visual obscurations lasting for few
seconds only.
 There was no history of any head trauma drug
intake, fits, unconsciousness, drowsiness and
diplopia
 Past Medical, Surgical Was Insignificant
 Belonged Middle Class

5.  General physical examination
The patient was healthy but anxious, was well
oriented in time , place and person.
Her vitals were:
Pulse - 60/min
B.P – 145/90mm hg
Afebrile
R/R – 15/min
 Systemic examination
(Non-conclusive)

6. EYE EXAMINATION
R L
VISUAL ACUITY 6/9 6/9
COLOUR VISION NORMAL NORMAL
PUPIL ROUND,REGULAR,
REACTIVE
ROUND,REGULAR,
REACTIVE
•EXAMINATIOM OF
ADNEXA AND ANTERIOR
SEGMENT OF EYE
BALL WAS NORMAL
•EXTRA OCULAR
MOVEMENTS WERE FULL
IN ALL DIRECTIONS OF
GAZE
Fundus : Bilateral Disc Edema

7. Fundus photographs of the patient

8.  PROVISIONAL DIAGNOSIS
BILATERAL ESTABLISHED PAPILLEDEMA
Cause ????????
Next step …………investigations

9. INVESTIGATIONS
 IN ADDITION TO ROUTINE
 VISUAL FIELDS
 CT SCAN HEAD

12. CT Scan
NON CONTRAST CT SCAN OF HEAD SHOWS
A 6x4cm LYTIC LESION IN BONY SKULL AT
LEFT PARIETO-OCCIPITAL REGION
CAUSING MODERATE COMPRESSION
ON ADJUCENT CEREBELLUM , OCCIPITAL
LOBE AND FORTH VENTRICLE.
There is mid line shift towards right along
with mild to moderate obstructed
hydrocephalus.
Conclusion: metastatic deposit in bone, DD
may include aggressive meningioma.

15.  Final diagnosis
Bilateral established papilledema as a
result of raised intracranial pressure,
because of left sided parieto-occipital space
occupying lesion.

16.  MANAGEMENT:
NEUROSURGICAL CONSULTATION
SURGERY TO REMOVE THE TUMOUR

26. PATIENT RECOVERING FROM SURGERY
Further management after the histo-
pathological report

27. Disc swelling
Optic disc edema

28. Disc edema

29. Definitions
 Papilledema is swelling of optic nerve head
secondary to raised intracranial pressure
 All other causes of disc swelling in absence
of raised ICP are called optic disc edema
 Pseudo papilledema is not true edema but
mimics optic disc edema.

30.  All patients with papilledema should be
suspected of having intracranial SOL, unless
proven otherwise.
 not all patients of intracranial SOL have
papilledema

31.  Any intra-cranial tumor may induce
papilledema.
 It is most evident with tumors in the
posterior fossa which obstruct the aqueduct
of Sylvius, and least likely to occur with
pituitary tumors.
 The site of the tumor is, more important
than its nature, its size and rate of growth.

32.  papilledema does not develop- if the optic
nerve has already become atrophic
 Unilateral papilledema with optic atrophy on
the other side, suggests a …….
frontal lobe tumor or an olfactory
meningioma of the opposite side –
the Foster-Kennedy Syndrome.

33. Causes of Optic Disc
swelling
1.Papilledema
2.Disc edema

34. (Increased Intra Cranial Pressure)
SOL Tumor Glioma, Metastassis, Meningioma,
Pituitary Adenoma, CP angle tumour
Hemorrhage
Trauma (hematoma, edema)
Increased CSF
production
Choroid plexus tumor
Reduced CSF
drainage
Blockage of ventricular
system
Tumor/cyst/infection
(congenital/acquired)
Damage to arachnoid
granulations
Meningitis/Sub Arachnoid
hemorrhage/cerebral
venous thrombosis
Idiopathic intracranial
hypertension
other Malignant hypertension
Causes of papilledema

36. Inflammatory Optic neuritis
uveitis
Granulamatous TB
Sarcoidosis
Infiltrative leukemia
lymphoma
Vascular AION
CRVO
DM papillitis
Tumours Optic nerve (meningioma,
glioma)
Hereditary LHON
Ocular hypotony
Causes of disc edema

37. Fundus Photographs of various
conditions that cause disc edema

41. CAUSES OF PSEUDO-PAPILLEDEMA
OPTIC DISC DRUSEN
TILTED DISC
MEDULATED NERVE FIBERS
CONGENETAL DISC ANOMALIES
HYLOID REMANENTS OVER THE OPTIC DISC
GLIAL TISSUE OVER THE OPTIC DISC
CONGENETAL FULLNESS OF OD ASSOCIATED
WITH HYPEROPIA

42. Fundus photographs of various
conditions causing psuedo disc
edema

46. Patho-physiolgy
 Sub arachniod space around the optic nerve
is continuous with sub arachniod space of
the brain
 When ever the CSF pressure increases it is
transmitted to optic nerve …….this causes
 Interruption of axoplasmic flow in the optic
nerve and
 venous congestion.

47. histopathology The of acute optic disc edema shows
1. axoplasmic stasis,
2. edema, and
3. vascular congestion
Peri-papillary hemorrhages are also seen
Physiological cup is filled by edema
Small blood vessels are engorged and tortuous
Neural retina is displaced
On electron microscopy
Engorgement of axons
axons are filled with swollen mitochondria

48. The tissue in front of the lamina cribrosa has become more
voluminous due to swelling of the nerve fibers and vascular
congestion. The tissue bulges towards the vitreous cavity and
pushes the retina sideways

49. COMMON PRESENTING
SYMPTOMS
 HEADACHE:
 EARLY MORNING
 PROGESSIVELY WORSINING (PATIENT
USUALLY PRESENTS IN HOSPITAL WITHIN
SIX WEEKS)
 MAY BE LOCALISED / GENERALISED
 TENDS TO GET AGGRAVATED WITH
BENDING, HEAD MOVEMENT OR COUGHING.

50.  VOMITING:
 SUDDEN , PROJECTILE , PARTIALLY
RELIEVING HEADACHE.
 CAN OCCUR AS AN ISOLATED FEATURE
 CAN PRECEDE THE ONSET OF HEADACHE BY
MONTHS (SPECIALLY IN FOURTH
VENTRICULAR TUMORS)
 DETERIORATION OF CONSCIOUSNESS:
 USUALLY SLIGHT, LEADING TO DROWSINESS
AND SOMNOLENCE
 DRAMATIC DETERIORATION OF
CONCIOUSNESS IS INDICATIVE OF
BRAINSTEM DISTORSION AND TENTORIAL /
TONSILAR HERNIATION.

51. VISUAL SYMPTOMS:
TRANSIENT VISUAL OBSCURATIONS (FLASHES,
BLACKOUTS , GREYOUTS)
HORIZONTAL DIPLOPIA
CAUSED BY STRETCHING OF SIXTH NERVE OVER THE
PETROUS TIP
VISUAL FAILURE (LATE BECAUSE OF SECONDARY OPTIC
ATROPHY).

52. STAGES OF PAPILLEDEMA
 1. EARLY
 2. ESTABLISHED
 3. CHRONIC
 4. ATROPHIC

53. VISION MECHANICAL
CHANGES
VACULAR CHANGES
NO VISUAL SYMPTOMS
VA -NORMAL
BLURRING OF MARGINS OF
OD
HYPEREMIA OF OD
LOSS OF SPONTANEOUS VENUS
PULSATIONS

54. VISION MECHANICAL changes VACULAR CHANGES
TRANSIENT VISUAL
DISTURBANCE
ENLARGING BLIND SPOT
ELEVATED DISC WITH
INDISTINCT MARGIN
CIRCUMFRENTIAL
RETINAL FOLDS (PATON’S
LINES)
SEVERE HYPERMIA
VENOUS TORTUOSITY AND DILATION
FLAME SHAPED HEMORRHAGES.
COTTON WOOL SPOTS
HARD EXUDATES, FOVEAL STAR
STAGE 2 ESTABLISHED

55. VISION MECHANICAL
CHANGES
VASCULAR CHANGES
VA – IMPAIRED
VISUAL FIELD
DEFECTS
GLIOSIS OF PERI-
PAPILLRAY NERVE FIBRE
LAYER
DECREASE IN HYPEREMIA ,COTTON WOOL SPOTS AND
HEMORRHAGES
OPTICOCILLIARY SHUNTS
SHEATING OF BLOOD VESSELS
STAGE 3 CHRONIC
PAPILLEDEMA
CHAMPAGNE CORK APPEARANCE

56. VISION MECHANICAL CHANGES VASCULAR CHANGES
SEVERELY
IMPAIRED VA
SWELLING DECREASES
SECONDARY OPTIC ATROPHY
DIRTY GREYISH WHITE
INDISTINCT MARGINS
NUMBER AND CALIBER of blood
vessels on the disc is reduced
STAGE 4 ATROPHIC SECONDARY OPTIC ATROPHY

57. Another grading of
papilledema especially for
benign intracranial
hypertension

58. Grade I papilledema is characterized by a C-
shaped halo with a temporal gap in the peri-
papillary nerve fiber layer

59. With Grade II papilledema, the halo becomes
circumferential

60. Grade III papilledema is characterized by loss
of major vessels AS THEY LEAVE the disc

61. Grade IV papilledema is characterized by loss of
major vessels ON THE DISC

62. Grade V papilledema has total obscuration of all
vessels of the disc.

63. it is extremely important to find out whether
Disc swelling present or not …..
And if there is disc swelling……is it
papilledema or optic neuritis .

64. •A careful history like hypertension, diabetes etc.,
should be taken. It should also include drug history
particularly over dosage of Vitamin A, oral
contraceptives, anti psychotics.
•A complete and thorough eye examination
comprising of visual acuity, visual fields, refraction
(with appropriate cycloplegic especially in children,
and slit lamp examination of the fundus, vitreous, and
macula).
Papilledema should be graded.

65. Difference between early
papilledema and normal disc
1. Rule out pseudo-disc-edema by typical
fundus appearance and other clinical signs
2. Spontaneous venous pulsations are present
80 % of the normal discs
3. For rest of 20 % do a FFA …..dye does not
leak in normal discs

66. Difference between papilledema
and other causes of disc edema
especially optic neuritis

67. history Headache, vomiting, Sudden loss of vision
VA normal Severely reduced
pain absent On movement of eye
especially superiorly
laterality bilateral unilateral
pupil normal RAPD
Disc swelling +3 dioptres Less than 3 dioptres
Hemorrhages/ exudates More in established less
Visual fields Enlargement of blind spot Central or centraocecal
scotoma
CT MRI SOL demyelination
Difference between papilledema and optic neuritis

68. INVESTIGATIONS
PERIMETRY:
SHOW ENLARGED BLIND SPOT IN
ESTABLISHED STAGE AND ARCUATE FIELD
DEFECTS IN LONG STANDING PAPILLEDEMA
B-SCAN:
SHOWS RAISED OPTIC DISC
NEUROIMAGING (CT/MRI):
TO LOCALIZE THE SPACE OCCUPYING
LEISION

69. FFA
ARTIRIAL
PHASE:
CONGESTED
CAPILLARIES ALONG
THE
NERVE FIBER LAYER.
AV PHASE HYPERFLOCESCENE OF
DILLATED
CAPILLARIES,
EXTENDING TO
ADJACENT RETINA.
LATE
PHASE
MARKED
HYPERFLORESCENCE
DUE TO LEAKAGE

70. A multidisciplinary approach is mandatory.
Ophthalmologist should guide the neuro-
physicians/surgeons about the urgency of treatment
by serially monitoring the
visual acuity
visual fields and
color vision
all these vital functions of eye change irreversibly
when the papilledema progresses from established
stage into chronic stage.
Neurophysician/surgeon should step up the anti-
edema measures or intervene surgically at the
earliest at this juncture

71.  Treatment:
Treatment of the cause
And reduction of the increased CSF
pressure by
Drugs
Shunt

72. CONCLUSION:
•Papilledema could be VISION AND LIFE
THREATENING
•all doctors should be well aware about the importance
of an eye examination in a case of headache when
associated with visual disturbances like diplopia and
vomiting.

73. Take home message
 PERSISTANT HEADACHES SHOULD NOT BE TAKEN
LIGHTLY
 FUNDUS EXAMINATION IS MANDATORY IN
CLINICAL EVALUATION OF SUCH PATIENTS.
 TIMELY REFFERAL OF SUCH PATIENTS TO
OPHTHALMOLOGY DEPARTMENT CAN BE LIFE AND
VISION SAVING.

74. Thank you