papilledema - dr shylesh dabke
DESCRIPTION
PapilledemaTRANSCRIPT
![Page 1: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/1.jpg)
Papilledema
Dr Shylesh B DabkeResident Dept. of OphthalmologyKasturba Medical CollegeMangalore
![Page 2: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/2.jpg)
Definition
▪ Passive hydrostatic non inflammatory swelling of optic nerve head secondary to raised intracranial pressure.
▪ Usually bilateral ; may be unilateral.
▪ Optic disc swelling in the absence of raised intracranial pressure is referred to as optic disc edema.
![Page 3: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/3.jpg)
Pathophysiology
Disturbance in axoplasmic flow causing stasis swelling of axons and leakage.
Increased intracranial pressure(ICT) is transmitted along subarachnoid space with optic nerve sheath acting as a tourniquet.
Increased ICT leads to increased optic nerve tissue pressure which alters pressure gradient resulting in stasis.
![Page 4: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/4.jpg)
![Page 5: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/5.jpg)
Theories of Genesis
Mechanical Theory
Ischemic Theory
In most cases combined mechanism operates.
![Page 6: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/6.jpg)
Causes(Bilateral)
Space occupying lesions.
Blockage of CSF flow. Reduction in CSF resorption.
Increased CSF production.
Idiopathic Intracranial Hypertension.
Focal or diffuse cerebral edema.
Reduction in size of Cranial Vault.
Vitamin A toxicity.
![Page 7: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/7.jpg)
Causes(Unilateral)
Foster kennedy syndrome
Previous unilateral optic atrophy.
Posterior fossa tumor.
Brain abcess.
Subarachnoid haemorrhage.
Optochiasmatic choroiditis.
![Page 8: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/8.jpg)
Symptoms(Ocular)
Transient obscuration of vision.
Central vision affected late.
Horizontal Diplopia.
Visual Acuity
![Page 9: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/9.jpg)
Symptoms(General)
Headache more in the morning, intensifies with head movement, coughing or straining.
Projectile vomiting.
Loss of consciousness/ generalized motor rigidity.
![Page 10: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/10.jpg)
Signs(Mechanical)
Elevation of the optic disc.
Blurring of the optic disc margin. Filling in of the physiological cup.
Edema of the peripapillary nerve fiber layer.
Retinal or choroidal folds(Paton’s lines) Macular fan.
![Page 11: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/11.jpg)
Signs(Vascular) Hyperemia of the optic disc.
Vascular congestion.
Peripapillary haemorrhage.
Exudates in the disc or peripapillary area.
Nerve fiber layer infarcts.
![Page 12: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/12.jpg)
Grading of Papilledema (according to severity and its
chronicity)
![Page 13: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/13.jpg)
Early Papilledema
Disc elevation.
Venous distention and tortuosity.
Obscuration of the normal disc margin and overlying retinal vessels.
Absence of spontaneous venous pulsations
![Page 14: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/14.jpg)
Established Papilledema
Marked elevation of nerve head with blurring of margins.
Engorged tortous venules.
Peripapillary splinter hemorrhages.
Cotton wool spots.
Hard exudates over the disc and macular area.
![Page 15: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/15.jpg)
Chronic Papilledema(Classical “Champagne cork appears of disc)
disc hyperemia decreases and disc progressively appears pale in color.
Opticociliary shunts and drusen like deposits may be present on the disc.
High water mark.
![Page 16: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/16.jpg)
Atropic Papilledema
Onset of optic disc pallor (secondary optic atrophy) .
Decrease in disc haemorrhage.
Narrowing of blood vessels and their ensheating.
Optic disc appears dirty white and blurred due to glial reaction.
![Page 17: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/17.jpg)
Papilledema Grading System (Frisen Scale)
![Page 18: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/18.jpg)
Grade 0
Mild nasal NFL elevation. Rare obscuration of a portion of major vessel (usually at superior pole)
![Page 19: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/19.jpg)
Grade 1 (Very early Papilledema)
Obscuration of nasal border of disc
Normal temporal disc margin
![Page 20: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/20.jpg)
Grade 2 (Early papilledema)
Obscuration of all the disc borders
Elevation of nasal border
No major vessel obscuration
![Page 21: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/21.jpg)
Grade 3 (Moderate papilledema)
Obscuration of all borders
Increased diameter of optic nerve head
Obscuration of segment of major blood vessels as they pass disc margin.
![Page 22: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/22.jpg)
Grade 4 (Marked papilledema)
Elevation of entire nerve head
Obscuration of all the borders
A segment of major vessel obscured on the disc
![Page 23: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/23.jpg)
Grade 5 (Severe papilledema)
Anterior extension of optic nerve head
Total obscuration of vessel on disc surface
Obliteration of optic cup.
![Page 24: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/24.jpg)
Histopathological Findings
Acute disc edema
Accumulation of extracellular fluid in and anterior to retinal lamina cribrosa, with enlargement of subarachnoid space with stretching.
Engorgement of axons occurs in prelaminar portion.
![Page 25: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/25.jpg)
Sensory retinal changes
- Displacement of retina away from optic disc.
- Buckling of the outer layers of retina.
- Displacement of rods and cones away from their anchor near Bruch’s membrane.
- Serious RD in peripapillary area.
![Page 26: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/26.jpg)
Electron microscopy of axons
- Axonal swelling and accumulation of mitochondria.
- Mitochondrial swelling and disruption.
- Disruption of fascicles of the microtubules.
![Page 27: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/27.jpg)
Chronic disc edema
Degenerative and fibrotic changes in both anterograde and retrograde manner.(hence atropy may occur anywhere from retinal nerve fiber layer to optic nerve)
![Page 28: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/28.jpg)
Visual field changes
![Page 29: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/29.jpg)
Enlargment of blind spot.
Earliest loss of visual field commonly involves inferior nasal quadrent.
Peripheral concentric constriction.
![Page 30: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/30.jpg)
Relative scotoma (first to green and red).
Complete blindness.
In all cases visual field changes should be monitored carefully and decompression to be done before peripheral constriction sets in.
![Page 31: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/31.jpg)
Differential diagnosis of Papilledema
Papillitis. Pseudopapilledema. - Drusen of optic disc. - High Hypermetropia (crowded nerve fibers at disc). - AION. Optic neuritits. Tilted optic disc. Hypoplastic disc. Myelinated nerve fibers.
![Page 32: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/32.jpg)
Papillitis
![Page 33: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/33.jpg)
Pseudopapilledema - Drusen of Optic disc
![Page 34: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/34.jpg)
Pseudopapilledema - Hyperopic disc
![Page 35: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/35.jpg)
Tilted optic disc
![Page 36: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/36.jpg)
Hypoplastic disc
![Page 37: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/37.jpg)
Myelinated nerve fibers
![Page 38: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/38.jpg)
History and physical examination including blood pressure measurement.
Ophthalmic examination - In addition to fundus examination, assessment of visual acuity, pupillary examination, ocular motility & alignment, and visual fields.
MRI with or without contrast is the best investigation of choice.
Investigations
![Page 39: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/39.jpg)
CT Scan To rule out - Intracranial lesions. - Obstructive hydrocephalus.
Can detect - Subarachnoid, epidural & subdural hemorrhages. - Acute infarctions. - Cerebral edema. Contraindication for MRI.
![Page 40: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/40.jpg)
Lumbar puncture
Diagnostic - Recording opening pressure.
CSF for microbial and infectious studies.
Therapeutic procedure - Pseudotumor cerebri
![Page 41: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/41.jpg)
Fundus Fluoroscence Angiography(FFA)
Early Phase disc capillary dilation Dye leakage spots Microaneurysm over the disc
Late Phase Leakage of dye beyond disc margin Pooling of dye around the disc
![Page 42: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/42.jpg)
Treatment directed at underlying cause.
Timely intervention has a remarkable effect on prognosis. (unless nerve is irreversibly damaged)
Vision recovery is faster then subsidence of fundus features.
Treatment
![Page 43: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/43.jpg)
Brain Tumor
- Craniotomy to remove tumor.
Resolution of papilledema within 6-8weeks.
![Page 44: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/44.jpg)
Pseudotumor Cerebri
- Surgical
Repeated Lumbar puncture Decompression Shunting procedure
Resolution of papilledema within 2-3weeks of shunt procedure.
- Medical
Acetazolamide Oral Glycerol Corticosteroids Weight reduction
![Page 45: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/45.jpg)
Papilledema in PIH General – bed rest.
Control of BP.
Control of edema – Diuretic, Hypertonic glucose.
Non responders – Termination of pregnancy.
![Page 46: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/46.jpg)
Surgical Decompression
Indications Failure of Medical treatment - Marked disc swelling(>5D) - Engorged veins - Extensive hemorrhages - Early exudate spots - Progressive headache
Progressive optic neuropathy (early field constriction)
Direct Fenestration of optic nerve sheath.
![Page 47: Papilledema - Dr Shylesh Dabke](https://reader036.vdocuments.us/reader036/viewer/2022062312/554b0537b4c905c12d8b5197/html5/thumbnails/47.jpg)
Therapeutic success
Relief of headache.
Transient visual obscuration decreased.
Stability/ improvement of field defects.