1.Guide: Dr Anupama Karanth Presenter: Dr Madhurima

2. Causes of pseudo disc edema Optic nerve head drusen : disc elevation Medullated nerve fibres : blurred margins Morning glory syndrome: elevated disc Tilted disc: blurred margins Small hyperopic disc: hyperemic disc Optic disc dysplasia Bergmeisters papilla 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 6. Obliquely entering nerve, inferonasal chorioretinal thinning Bitemporal hemianopia Blurred margin Nasally entering vessels 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 15. Early papilledema Chronic papilledema Atrophic papilledema Established papilledema Yanoff and Duker 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 17. Papilledema Papillitis Disc elevation 2-6 D Does not exceed 2-3D Venous engorgement, peripapillary hemorrhages More frequent Less frequent 18. Papilledema Check BP Stage IV hypertensive retinopathy Bilateral disc edema, other signs of raised ICT 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 23. Diagnosis is made by MR venogram Right transverse sinus thrombosis 24. Papilledema Check BP Hypertensive retinopathy Neuro imaging Abnormal Normal Intracranial space occupying lesions Lumbar puncture Opening pressure high Idiopathic intracranial hypertension Normal opening pressure Abnormal spinal fluid analysis Meningitis 25. Anterior optic neuropathy Inflammatory optic neuropathy Ischemic optic neuropathy Compressive optic neuropathy Toxic and hereditary optic neuropathy Infiltrative optic neuropathy Intraocular causes CRVO, posterior uveitis, posterior scleritis, hypotony Neuro retinitis/ ODEMS 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 250mm H2O: raised ICT MS: oligoclonal bands Decreased glucose, increased proteins: meningitis 6. Ultrasound Optic disc drusen- B Scan 51. 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 52. 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. 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 54. A 9 year old boy, intermittent headache and bouts of abdominal pain since 3 months, no h/o recent infections, systemic medications General examination was unremarkable Vision BE 6/6, N6, color vision BE within normal limits, pupils and visual fields were normal Bilateral Optic Disc Swelling as the Presenting Sign of Pheochromocytoma in a Child Medscape J Med. 2008;10(7):176 2008 Medscape 55. Bilateral Optic Disc Swelling as the Presenting Sign of Pheochromocytoma in a Child Medscape J Med. 2008;10(7):176 2008 Medscape 56. BP-220/140mm Hg On further questioning, frequent micturition and excessive sweating was reported Abdominal USG and MRI revealed a right sided suprarenal mass Increased urine catecholamines Diagnosis: Pheochromocytoma Bilateral Optic Disc Swelling as the Presenting Sign of Pheochromocytoma in a Child Medscape J Med. 2008;10(7):176 2008 Medscape 57. Thank you