Hue, Jennifer - Pap Ill Edema

8/3/2019 Hue, Jennifer - Pap Ill Edema

1/19

Papilledema &Pseudopapilledema

Jennifer HueIntegrative seminar Fall 2011


2/19

Case Presentation

CC: 47 y/o WF for VFSS24-2 f/u OS

Active Hx: myopia, pseudo-papilledema OS

BCVA: 20/20 OD, OS, OU Externals WNL

Current Rx:

OD -4.75 sph OS -4.25 sph


3/19

Additional Testing

VFSS24-2 3 pts flagged centrally & inferonasally only 1 pt repeatable, but overall consistent with

previous VF in 2010 9/14 fixation losses

Red cap desaturation

OD/OS: both central & peripheral caps equal

Fundus photo, on comparison to 2010 photos: no change in appearance, ONH borders &

vessels appear stable OD/OS


4/19

Assessment & Plan

A: Pseudo-papilledema OS ONH appears stable, performed VFSS24-2 Fundus photos taken

P: RTC 2 mos for GDx OD/OS & VF Sita-Fastscreening OD/OS (pt unable to maintain steady fixationwith SS24-2)

Pt edu on physiological variation of ONH as of currentinfo from testing.


5/19

2010


6/19

2011


7/19

Pseudopapilledema

Causes most commonly produced by optic disc drusen; may

be buried within disc and therefore not visible drusen may be from axonal degeneration from

altered axomplasic flow drusen tends to be on surface in adults >

children high hyperopia with heaping up of nerve fibers

Characteristics incidence = 20 in 1000 present in whites >> blacks

VF defects: ~70% in those with visible drusen;~35% in those without

VA normal, (-) visual sx's


8/19

Feature Early papilledema Pseudo-papilledma

disc color hyperemic pink, yellowish-pink

disc margins indistinct early irregularly blurred, may be lumpy

disc elevation minimal minimal to marked, center of disc ismost elevated

vessels normal distribution, (-) SVP emanate from center, frequentanomalous pattern, (+/-) SVP

NFL dull due to edema, which may beobscuring blood vessels

NO EDEMA; may glisten

hemorrhages more flame-shaped more dot-blot

Differential Dx


9/19

Pathogenesis of Papilledema

Elevated intracranial pressure ==> elevated CSFpressure in the subarachnoid space of theintraorbital portion of optic nerve

Nerve fibers within the optic nerve arecompressed

Obstruction of axoplasmic flow, which appears tobe the primary cause of optic disc swelling

This results in axonal & retinal ganglion celldestruction

Axoplasmic stasis leads to venous obstruction &dilation, hypoxia of the NFL & vasculartelangiectasias of the optic discs


10/19

Ophthalmoscopic Features

Bilateral disc edema: may be asymmetric, but rarely unilateral Opacification of peripapillary NFL Disc hyperemia Loss of SVP; (+) SVP is a good sign --> indicates that the ICP


11/19

Classification of Papilledema

Early: disc changes before dev't

of obvious disc swelling opacification of

peripapillary NFL(obscuring sup & inf discmargins)

disc hyperemia fromdilation of capillaries ondisc surface (use red-freefilter)

http://content.lib.utah.edu/cdm4/item_viewer.php?CISOROOT=/EHSL-WFH&CISOPTR=251
http://content.lib.utah.edu/cdm4/item_viewer.php?CISOROOT=/EHSL-WFH&CISOPTR=251http://content.lib.utah.edu/cdm4/item_viewer.php?CISOROOT=/EHSL-WFH&CISOPTR=251http://content.lib.utah.edu/cdm4/item_viewer.php?CISOROOT=/EHSL-WFH&CISOPTR=251


12/19


Fully developed: the surface of disc liesabove plane of retina

small & large vessels buried usu. accompanied by flame-

shaped hemorrhages &

CWS Paton's folds:

circumferential retinal folds(may be due to the lateraldisplacement of retina)

possible presence of

macular star

http://webeye.ophth.uiowa.edu/eyeforum/cases/papilledema-grading.htm
http://webeye.ophth.uiowa.edu/eyeforum/cases/papilledema-grading.htmhttp://webeye.ophth.uiowa.edu/eyeforum/cases/papilledema-grading.htm


13/19


Chronic: with persistence of

elevated IOP overmonths, hemorrhagic &exudative components

resolve disc develops a

"champagne cork"appearance

obliteration of central cup ONH appears milky gray

http://www.osnsupersite.com/view.aspx?rid=29815
http://www.osnsupersite.com/view.aspx?rid=29815http://www.osnsupersite.com/view.aspx?rid=29815


14/19


Post-papilledema atrophy: disc is atrophic & grayish-

white narrowed, sheathed

vessels significant visual field,

color vision & VA lossfrom chronic obstruction ofcentral retinal veinousdrainage

http://eyewiki.aao.org/Papilledema
http://eyewiki.aao.org/Papilledema


15/19

Associated Clinical Features

Visual symptoms

in both early & fully developed papilledema, pts are usuallyasymptomatic

this is useful in differentiating from other types of discswelling, such as inflammation or ischemia.

possible transient dimming of vision VA loss - in late stage; occurs gradually & only after severe

peripheral field loss VF defect - enlargement of blind spot is most common and often theonly VF defect; however, this is not helpful in early dx bc discswelling is visible on o-scope viewing prior to this field change

Pupillary function - normal in early papilledema afferent pupillary defect may be present in eye with larger visual

field loss

Diplopia - increased intracranial pressure may result in abducensnerve palsies


16/19

Management

Long-term lowering of intracranial pressure neurosurgical intervention if imaging reveals

mass lesion if lesion cannot be removed, then alternate

procedure for diverting CSF is indicated (i.e.

shunt) Surgery for decompression of optic nerve sheath

does not lower ICP, but 2/3 of pts reportimprovement in HA's

long-term improvements in visual fcn & opticdisc edema have been noted


17/19

Visual Prognosis

difficult to determine! disc pallor & vascular sheathing signify irreversible

changes in nerve tissue

extensive field loss, color vision abnormalities, &afferent pupillary defect indicate at least somepermanent visual damage

severe venous engorgement, retinal hemorrhages,

and exudates are ofno significance


18/19

The efficacy of optic nerve ultrasonography for differentiatingpapilloedema from pseudopapilloedma in eyes with swollen opticdiscs

Neudorfer, et al.

Methods: prospective study that evaluated 44 pts with bilateral optic discswelling who underwent a thorough neuro-ophthalmic exam, whichincluded optic nerve ultrasound (A- & B-mode); findings were comparedwith clinical assessment.

Results: U/S detected papilloedema with:

high sensitivity: 85% when normal optic nerve width was set at


19/19

References

Kline, L. B. & Foroozan, R. (2007). Optic Nerve Disorders, 2nd Ed. NewYork: Oxford University Press.

Neudorfer, M., & Siegman, M., et al. Acta

Ophthalmologica. The efficacy of optic nerveultrasonography for differentiating papilloedema from pseudopapilloedema in eyes with swollen optic discs,September 2011, 1-5.

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Hue, Jennifer - Pap Ill Edema