Papilledema

  • Swelling of optic disc caused by increased intracranial pressure
  • Patient may report transient black-outs of vision, especially upon standing
  • Patient need not report headache or other non-visual symptoms
  • Optic disc margins indistinct
  • Optic disc elevated above retinal surface
  • These signs may be ophthalmoscopically subtle
  • In acute phase, may see hemorrhages and cotton wool spots
  • In chronic phase, optic disc elevation and blurred margins, but no hemorrhages or cotton wool spots
  • In atrophic phase (optic nerve axons have died), optic disc shows mixture of pallor and swelling
  • Vision usually normal or near normal unless atrophy has set in
  • Congenitally elevated optic disc, but features of dysplasia usually present and visual function usually preserved
  • Non-arteritic ischemic optic neuropathy, but patient reports acute unilateral vision loss, and optic disc swelling usually unilateral
  • Arteritic ischemic optic neuropathy in giant cell arteritis, but patient usually has systemic symptoms
  • Optic neuritis, but patient reports acute vision loss and sometimes periocular pain in affected eye on gaze from side to side
  • Compressive optic neuropathy from mass in orbit or optic canal, but lesion visible on imaging
  • Infiltrative optic neuropathy from metastatic cancer or systemic inflammation like sarcoidosis, but there is usually evidence of cancer or inflammation elsewhere
  • Leber hereditary optic neuropathy, but usually unilateral and optic disc is hyperemic
  • Central retinal vein occlusion, but that has more hemorrhage and less optic disc swelling
  • Terson syndrome, but only in setting of severe body trauma or pancreatitis
  • Distinguishing these causes of optic disc edema is challenging
  • Refer emergently (within 24 hours) to ophthalmologist if you detect elevated optic discs and patient has visual, neurologic, or constitutional symptoms
  • Refer urgently (within 48 hours) if you detect elevated optic discs in an asymptomatic patient
  • Ophthalmologist will try to determine cause of elevated optic disc
  • If papilledema is suspected, patient will undergo immediate neurologic examination and brain imaging
  • If arteritic ischemic optic neuropathy is suspected, patient will undergo prompt intensive corticosteroid treatment and temporal artery biopsy
  • If compressive optic neuropathy is suspected, patient will undergo orbit and brain imaging
  • If infiltrative optic neuropathy is suspected, patient will undergo orbit/brain imaging, lumbar puncture, and search for evidence of metastatic cancer or systemic inflammation
  • If Leber optic neuropathy is suspected, patient will undergo blood testing for appropriate mitochondrial gene mutations
  • Undiagnosed chronic papilledema may lead to death of optic nerve axons and dreadful and irreversible vision loss, therefore...
  • Early detection of papilledema is critical, not only to discover and treat its cause, but to relieve pressure on optic nerves