### Date : 2024-08-23 12:27 ### Topic : Papilledema #ophthalmology #neurology ---- ### Papilledema Overview **Papilledema** is the swelling of the optic disc due to increased intracranial pressure (ICP). It’s a critical sign often indicating serious underlying conditions, such as **intracranial mass lesions, hemorrhage, meningitis, or cerebral edema.** It is a medical emergency because it can lead to irreversible vision loss if not promptly addressed. ### Pathophysiology - **Increased Intracranial Pressure:** The optic nerve sheath is continuous with the subarachnoid space, so increased pressure in the cerebrospinal fluid (CSF) around the brain is transmitted to the optic nerve head. - **Axoplasmic Flow Stasis:** Elevated ICP leads to stasis of axoplasmic flow within the optic nerve, resulting in swelling of the nerve fibers and the optic disc. - **Venous Congestion:** Increased pressure compresses the central retinal vein, leading to congestion and further exacerbation of disc swelling. ### Causes - **Intracranial Mass Lesions:** Tumors, abscesses, or hematomas. - **Hydrocephalus:** Blockage in CSF flow causing increased pressure. - **Idiopathic Intracranial Hypertension (IIH):** Also known as pseudotumor cerebri, often seen in obese women of childbearing age. - **Cerebral Venous Sinus Thrombosis:** Thrombosis in the venous sinuses leading to impaired CSF absorption. ### Clinical Features - **Visual Symptoms:** - **Transient Visual Obscurations:** Brief episodes of visual dimming, often lasting seconds. - **Visual Field Defects:** Initially, peripheral vision may be affected, especially the inferior fields. - **Decreased Visual Acuity:** This is usually a late sign. - **Other Symptoms:** - **Headache:** Typically worse in the morning or when lying down. - **Nausea and Vomiting:** Due to increased ICP. - **Diplopia:** From sixth nerve palsy due to increased pressure. - **Fundoscopic Examination:** - **Blurring of Disc Margins:** Early sign. - **Hyperemia:** The optic disc appears more red and swollen. - **Hemorrhages:** Flame-shaped hemorrhages around the disc. - **Paton’s Lines:** Retinal folds that may radiate from the disc. - **Absence of Venous Pulsation:** Normally visible, but absent in papilledema. ### Diagnostic Workup - **Neuroimaging:** - **MRI or CT Scan:** To identify mass lesions, hydrocephalus, or other structural causes of increased ICP. - **MR Venography:** Useful for detecting cerebral venous sinus thrombosis. - **Lumbar Puncture:** - Performed after neuroimaging to measure opening pressure and analyze CSF (after ruling out mass lesions). - **Ophthalmologic Assessment:** - **Visual Field Testing:** To assess the extent of visual field loss. - **Optical Coherence Tomography (OCT):** To measure the thickness of the retinal nerve fiber layer. ### Management - **Treat Underlying Cause:** The primary focus should be on addressing the cause of increased ICP. - **Medications:** - **Acetazolamide:** Reduces CSF production and helps lower ICP. - **Steroids:** May be used in specific cases like inflammatory causes. - **Surgical Interventions:** - **CSF Shunting:** In cases of hydrocephalus. - **Optic Nerve Sheath Fenestration:** Considered for vision preservation in IIH. - **Decompressive Craniectomy:** In cases of severe, refractory intracranial hypertension. - **Monitoring:** Frequent follow-up with ophthalmology to monitor visual function and disc appearance is crucial. ### Key Points to Remember - Papilledema is always a sign of increased intracranial pressure; hence, it’s a medical emergency. - Prompt diagnosis and management are crucial to prevent permanent vision loss. - A multidisciplinary approach, often involving neurologists, neurosurgeons, and ophthalmologists, is necessary for optimal patient care. ### Reference: - ### Connected Documents: -