Papilledema

Papilledema is defined as swelling or edema of the optic discs; it is usually bilateral and is due to increased intracranial pressure. Clinically, the disk appears elevated and the margins appear indistinct or blurred with obscuring of some small and medium vessels. Patients may present with transient visual loss (lasting seconds), often precipitated by changes in posture. Papilledema is also commonly associated with headache, double vision, nausea, and vomiting. Patients very rarely have decreased visual acuity.

Differential Diagnosis

Optic disc swelling due to increased ICP

• Pseudotumor cerebri (idiopathic intracranial hypertension)
  –Most common cause of papilledema
  –Young, obese, or pregnant females
  –Associated with vitamin A overdose, OCPs, tetracycline, steroid withdrawal
• Cerebral tumor (primary or metastatic)
• Hydrocephalus (e.g., tumor, Arnold-Chiari malformation, aqueductal stenosis, postinfectious)
• Intracranial hemorrhage (papilledema may not be seen acutely because it takes about 24 hours to develop after the ICP increases)
  –Subdural hematoma
  –Subarachnoid hemorrhage
  –Hemorrhagic stroke
  –Epidural hematoma
• Intracranial infection
  –Brain abscess
  –Encephalitis (e.g., herpes)
  –Neurosyphilis
  –Toxoplasmosis
• Meningitis (e.g., bacterial, viral, TB)
• Malignant hypertension
• Pre-eclampsia
  Optic disc swelling not due to increased ICP
• Pseudopapilledema (the vessels traversing the disk margins are obscured, as in true papilledema): Optic disc drusen or congenitally anomalous disc
• Papillitis: Unilateral, painful, vitreous cells
• Papillophlebitis: Mild visual loss and disk swelling in young, healthy patient
• Central retinal vein occlusion: Unilateral, associated with an acute loss of vision
• Diabetic papillopathy: Disk edema with minimal visual loss, resolves spontaneously
• Optic-disc vasculitis/ischemic optic neuropathy (giant cell/temporal arteritis)
• Orbital optic-nerve tumors
• Graves’ ophthalmopathy: History of thyroid dysfunction; may be associated with lid lag, proptosis, increased intraocular pressure
• Uveitis: Associated with pain, photophobia, and scleral injection
• Atypical optic neuritis

Workup and Diagnosis

• Papilledema is considered a medical emergency caused by increased intracranial pressure until proven otherwise

• Complete neurologic and ocular exam, including a color vision assessment, slit lamp exam, posterior vitreous evaluation for WBCs, and a dilated fundus exam
  –True papilledema presents as bilaterally swollen, hyperemic discs with blurring of the disc margin that often obscures the blood vessels
  –True papilledema is due to increased ICP; if spontaneous venous pulsations are present, then ICP is normal
• Noncontrast CT and/or MRI of the head/orbit will identify cerebral tumors, hydrocephalus, and intracranial hemorrhage
  –Pseudotumor cerebri have normal CT/MRI
  –Cerebral tumors appear as space-occupying lesions
  –Hydrocephalus appears as enlarged ventricles
• Lumbar puncture (if CT/MRI negative)
  –Opening pressure for pseudotumor cerebri
  –Definitive diagnosis of meningitis and encephalitis
  –CSF CBC, Gram stain, cultures (bacterial, viral, VDRL if neurosyphilis is suspected, and fungal), cryptococcal antigen, protein, glucose,
  –Bloody tap in subarachnoid hemorrhage
• Further laboratory studies may include CBC, thyroid tests (e.g., TSH, T₃, T₄), and blood glucose

Treatment

• Pseudotumor cerebri may be self-limited with weight loss, discontinuation of offending medications; diuretics may be used (e.g., acetazolamide) to decrease CSF production, lumboperitoneal shunting or optic nerve sheath decompression may be indicated in some cases
• Intracranial tumors may require resection
• Hydrocephalus: Surgical correction of anatomic abnormalities, with or without VP shunt
• Intracranial hemorrhage: Conservative management versus surgical evacuation depends on size and location
  –Acute subdural hematoma: Control elevated ICP with osmotic and loop diuretics and mild hyperventilation; emergent craniotomy for evacuation of hematomas that result in significant mass effect
  –Epidural hematoma: Usually does not require surgery; hyperventilation and mannitol to decrease ICP
• Intracerebral infections require appropriate antibiotics
• Encephalitis: Control ICP by hyperventilation, diuresis
• Malignant hypertension: Aggressive IV pressure control

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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