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OPTIC DISC SWELLING
Dr Abdul Munim Khan
Associate Professor & HOD
Ophthalmology
Dr Khawaja Abdul Hamid
Assistant Professor...
CASE PRESENTATION
Patient xyz, 35 year old female, housewife, married with
three children
Resident of Khaiaban-e-Sir Syed,...
The headache occurred mostly early in the morning
Severe and generalized in nature.
It was Aggravated by coughing.
Relived...
 The patient also complained of posture related
vague, visual obscurations lasting for few
seconds only.
 There was no h...
 General physical examination
The patient was healthy but anxious, was well
oriented in time , place and person.
Her vita...
EYE EXAMINATION
R L
VISUAL ACUITY 6/9 6/9
COLOUR VISION NORMAL NORMAL
PUPIL ROUND,REGULAR,
REACTIVE
ROUND,REGULAR,
REACTIV...
Fundus photographs of the patient
 PROVISIONAL DIAGNOSIS
BILATERAL ESTABLISHED PAPILLEDEMA
Cause ????????
Next step …………investigations
INVESTIGATIONS
 IN ADDITION TO ROUTINE
 VISUAL FIELDS
 CT SCAN HEAD
CT Scan
NON CONTRAST CT SCAN OF HEAD SHOWS
A 6x4cm LYTIC LESION IN BONY SKULL AT
LEFT PARIETO-OCCIPITAL REGION
CAUSING MOD...
 Final diagnosis
Bilateral established papilledema as a
result of raised intracranial pressure,
because of left sided par...
 MANAGEMENT:
NEUROSURGICAL CONSULTATION
SURGERY TO REMOVE THE TUMOUR
PATIENT RECOVERING FROM SURGERY
Further management after the histo-
pathological report
Disc swelling
Optic disc edema
Disc edema
Definitions
 Papilledema is swelling of optic nerve head
secondary to raised intracranial pressure
 All other causes of ...
 All patients with papilledema should be
suspected of having intracranial SOL, unless
proven otherwise.
 not all patient...
 Any intra-cranial tumor may induce
papilledema.
 It is most evident with tumors in the
posterior fossa which obstruct t...
 papilledema does not develop- if the optic
nerve has already become atrophic
 Unilateral papilledema with optic atrophy...
Causes of Optic Disc
swelling
1.Papilledema
2.Disc edema
(Increased Intra Cranial Pressure)
SOL Tumor Glioma, Metastassis, Meningioma,
Pituitary Adenoma, CP angle tumour
Hemorrhag...
Inflammatory Optic neuritis
uveitis
Granulamatous TB
Sarcoidosis
Infiltrative leukemia
lymphoma
Vascular AION
CRVO
DM papi...
Fundus Photographs of various
conditions that cause disc edema
CAUSES OF PSEUDO-PAPILLEDEMA
OPTIC DISC DRUSEN
TILTED DISC
MEDULATED NERVE FIBERS
CONGENETAL DISC ANOMALIES
HYLOID REMANEN...
Fundus photographs of various
conditions causing psuedo disc
edema
Patho-physiolgy
 Sub arachniod space around the optic nerve
is continuous with sub arachniod space of
the brain
 When ev...
histopathology The of acute optic disc edema shows
1. axoplasmic stasis,
2. edema, and
3. vascular congestion
Peri-papilla...
The tissue in front of the lamina cribrosa has become more
voluminous due to swelling of the nerve fibers and vascular
con...
COMMON PRESENTING
SYMPTOMS
 HEADACHE:
 EARLY MORNING
 PROGESSIVELY WORSINING (PATIENT
USUALLY PRESENTS IN HOSPITAL WITH...
 VOMITING:
 SUDDEN , PROJECTILE , PARTIALLY
RELIEVING HEADACHE.
 CAN OCCUR AS AN ISOLATED FEATURE
 CAN PRECEDE THE ONS...
VISUAL SYMPTOMS:
TRANSIENT VISUAL OBSCURATIONS (FLASHES,
BLACKOUTS , GREYOUTS)
HORIZONTAL DIPLOPIA
CAUSED BY STRETCHING OF...
STAGES OF PAPILLEDEMA
 1. EARLY
 2. ESTABLISHED
 3. CHRONIC
 4. ATROPHIC
VISION MECHANICAL
CHANGES
VACULAR CHANGES
NO VISUAL SYMPTOMS
VA -NORMAL
BLURRING OF MARGINS OF
OD
HYPEREMIA OF OD
LOSS OF ...
VISION MECHANICAL changes VACULAR CHANGES
TRANSIENT VISUAL
DISTURBANCE
ENLARGING BLIND SPOT
ELEVATED DISC WITH
INDISTINCT ...
VISION MECHANICAL
CHANGES
VASCULAR CHANGES
VA – IMPAIRED
VISUAL FIELD
DEFECTS
GLIOSIS OF PERI-
PAPILLRAY NERVE FIBRE
LAYER...
VISION MECHANICAL CHANGES VASCULAR CHANGES
SEVERELY
IMPAIRED VA
SWELLING DECREASES
SECONDARY OPTIC ATROPHY
DIRTY GREYISH W...
Another grading of
papilledema especially for
benign intracranial
hypertension
Grade I papilledema is characterized by a C-
shaped halo with a temporal gap in the peri-
papillary nerve fiber layer
With Grade II papilledema, the halo becomes
circumferential
Grade III papilledema is characterized by loss
of major vessels AS THEY LEAVE the disc
Grade IV papilledema is characterized by loss of
major vessels ON THE DISC
Grade V papilledema has total obscuration of all
vessels of the disc.
it is extremely important to find out whether
Disc swelling present or not …..
And if there is disc swelling……is it
papill...
•A careful history like hypertension, diabetes etc.,
should be taken. It should also include drug history
particularly ove...
Difference between early
papilledema and normal disc
1. Rule out pseudo-disc-edema by typical
fundus appearance and other ...
Difference between papilledema
and other causes of disc edema
especially optic neuritis
history Headache, vomiting, Sudden loss of vision
VA normal Severely reduced
pain absent On movement of eye
especially sup...
INVESTIGATIONS
PERIMETRY:
SHOW ENLARGED BLIND SPOT IN
ESTABLISHED STAGE AND ARCUATE FIELD
DEFECTS IN LONG STANDING PAPILLE...
FFA
ARTIRIAL
PHASE:
CONGESTED
CAPILLARIES ALONG
THE
NERVE FIBER LAYER.
AV PHASE HYPERFLOCESCENE OF
DILLATED
CAPILLARIES,
E...
A multidisciplinary approach is mandatory.
Ophthalmologist should guide the neuro-
physicians/surgeons about the urgency o...
 Treatment:
Treatment of the cause
And reduction of the increased CSF
pressure by
Drugs
Shunt
CONCLUSION:
•Papilledema could be VISION AND LIFE
THREATENING
•all doctors should be well aware about the importance
of an...
Take home message
 PERSISTANT HEADACHES SHOULD NOT BE TAKEN
LIGHTLY
 FUNDUS EXAMINATION IS MANDATORY IN
CLINICAL EVALUAT...
Thank you
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
Optic disc swelling
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Optic disc swelling

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

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Optic disc swelling

  1. 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. 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. 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. 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. 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. 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. 7. Fundus photographs of the patient
  8. 8.  PROVISIONAL DIAGNOSIS BILATERAL ESTABLISHED PAPILLEDEMA Cause ???????? Next step …………investigations
  9. 9. INVESTIGATIONS  IN ADDITION TO ROUTINE  VISUAL FIELDS  CT SCAN HEAD
  10. 10. 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.
  11. 11.  Final diagnosis Bilateral established papilledema as a result of raised intracranial pressure, because of left sided parieto-occipital space occupying lesion.
  12. 12.  MANAGEMENT: NEUROSURGICAL CONSULTATION SURGERY TO REMOVE THE TUMOUR
  13. 13. PATIENT RECOVERING FROM SURGERY Further management after the histo- pathological report
  14. 14. Disc swelling Optic disc edema
  15. 15. Disc edema
  16. 16. 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.
  17. 17.  All patients with papilledema should be suspected of having intracranial SOL, unless proven otherwise.  not all patients of intracranial SOL have papilledema
  18. 18.  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.
  19. 19.  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.
  20. 20. Causes of Optic Disc swelling 1.Papilledema 2.Disc edema
  21. 21. (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
  22. 22. 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
  23. 23. Fundus Photographs of various conditions that cause disc edema
  24. 24. 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
  25. 25. Fundus photographs of various conditions causing psuedo disc edema
  26. 26. 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.
  27. 27. 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
  28. 28. 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
  29. 29. 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.
  30. 30.  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.
  31. 31. 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).
  32. 32. STAGES OF PAPILLEDEMA  1. EARLY  2. ESTABLISHED  3. CHRONIC  4. ATROPHIC
  33. 33. VISION MECHANICAL CHANGES VACULAR CHANGES NO VISUAL SYMPTOMS VA -NORMAL BLURRING OF MARGINS OF OD HYPEREMIA OF OD LOSS OF SPONTANEOUS VENUS PULSATIONS
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. Another grading of papilledema especially for benign intracranial hypertension
  38. 38. Grade I papilledema is characterized by a C- shaped halo with a temporal gap in the peri- papillary nerve fiber layer
  39. 39. With Grade II papilledema, the halo becomes circumferential
  40. 40. Grade III papilledema is characterized by loss of major vessels AS THEY LEAVE the disc
  41. 41. Grade IV papilledema is characterized by loss of major vessels ON THE DISC
  42. 42. Grade V papilledema has total obscuration of all vessels of the disc.
  43. 43. 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 .
  44. 44. •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.
  45. 45. 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
  46. 46. Difference between papilledema and other causes of disc edema especially optic neuritis
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51.  Treatment: Treatment of the cause And reduction of the increased CSF pressure by Drugs Shunt
  52. 52. 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.
  53. 53. 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.
  54. 54. Thank you

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