Download - Optic disc swelling
OPTIC DISC SWELLING
Dr Abdul Munim KhanAssociate Professor & HOD
Ophthalmology
Dr Khawaja Abdul Hamid
Assistant Professor Ophthalmology
Mohtarma Benazir Bhutto ShaheedMedical College Mirpur AJK
CASE PRESENTATION
Patient xyz, 35 year old female, housewife, married with three children
Resident of Khaiaban-e-Sir Syed, Rawalpindi
PRESENTING COMPLAINT
Severe headache …………..for the last four months
The headache occurred mostly early in the morning
Severe and generalized in nature.
It was Aggravated by coughing.
Relived with OTC analgesics
It was associated with vomiting, which was episodic and projectile and used to give transient relief to the headache
There was Progressive worsening in severity of headache
Decrease in response to analgesics occurred with time.
The patient also complained of posture related vague, visual obscurations lasting for few seconds only.
There was no history of any head trauma drug intake, fits, unconsciousness, drowsiness and diplopia
Past Medical, Surgical Was Insignificant
Belonged Middle Class
General physical examination
The patient was healthy but anxious, was well oriented in time , place and person.
Her vitals were:
Pulse - 60/min
B.P – 145/90mm hg
Afebrile
R/R – 15/min
Systemic examination
(Non-conclusive)
EYE EXAMINATION
R L
VISUAL ACUITY 6/9 6/9
COLOUR VISION NORMAL NORMAL
PUPIL ROUND,REGULAR,
REACTIVE
ROUND,REGULAR,
REACTIVE
•EXAMINATIOM OF ADNEXA AND ANTERIOR
SEGMENT OF EYEBALL WAS NORMAL
•EXTRA OCULAR MOVEMENTS WERE FULLIN ALL DIRECTIONS OF
GAZE
Fundus : Bilateral Disc Edema
Fundus photographs of the patient
PROVISIONAL DIAGNOSIS
BILATERAL ESTABLISHED PAPILLEDEMA
Cause ????????
Next step …………investigations
INVESTIGATIONS
IN ADDITION TO ROUTINE
VISUAL FIELDS
CT SCAN HEAD
CT ScanNON CONTRAST CT SCAN OF HEAD SHOWS
A 6x4cm LYTIC LESION IN BONY SKULL AT LEFT PARIETO-OCCIPITAL REGIONCAUSING MODERATE COMPRESSIONON ADJUCENT CEREBELLUM , OCCIPITAL LOBE AND FORTH VENTRICLE.
There is mid line shift towards right along with mild to moderate obstructed hydrocephalus.
Conclusion: metastatic deposit in bone, DD
may include aggressive meningioma.
Final diagnosis
Bilateral established papilledema as a result of raised intracranial pressure, because of left sided parieto-occipital space occupying lesion.
MANAGEMENT:
NEUROSURGICAL CONSULTATION
SURGERY TO REMOVE THE TUMOUR
PATIENT RECOVERING FROM SURGERY
Further management after the histo-pathological report
Disc swelling
Optic disc edema
Disc edema
Definitions
Papilledema is swelling of optic nerve head secondary to raised intracranial pressure
All other causes of disc swelling in absence of raised ICP are called optic disc edema
Pseudo papilledema is not true edema but mimics optic disc edema.
All patients with papilledema should be suspected of having intracranial SOL, unless proven otherwise.
not all patients of intracranial SOL have papilledema
Any intra-cranial tumor may induce papilledema.
It is most evident with tumors in the posterior fossa which obstruct the aqueduct of Sylvius, and least likely to occur with pituitary tumors.
The site of the tumor is, more important than its nature, its size and rate of growth.
papilledema does not develop- if the optic nerve has already become atrophic
Unilateral papilledema with optic atrophy on the other side, suggests a …….
frontal lobe tumor or an olfactory meningioma of the opposite side –
the Foster-Kennedy Syndrome.
Causes of Optic Disc swelling
1.Papilledema2.Disc edema
(Increased Intra Cranial Pressure)
SOL Tumor Glioma, Metastassis, Meningioma, Pituitary Adenoma, CP angle tumour
Hemorrhage
Trauma (hematoma, edema)
Increased CSF production
Choroid plexus tumor
Reduced CSFdrainage
Blockage of ventricular system
Tumor/cyst/infection (congenital/acquired)
Damage to arachnoidgranulations
Meningitis/Sub Arachnoidhemorrhage/cerebralvenous thrombosis
Idiopathic intracranial hypertension
other Malignant hypertension
Causes of papilledema
Inflammatory Optic neuritis
uveitis
Granulamatous TB
Sarcoidosis
Infiltrative leukemia
lymphoma
Vascular AION
CRVO
DM papillitis
Tumours Optic nerve (meningioma, glioma)
Hereditary LHON
Ocular hypotony
Causes of disc edema
Fundus Photographs of various conditions that cause disc edema
CAUSES OF PSEUDO-PAPILLEDEMA
OPTIC DISC DRUSEN
TILTED DISC
MEDULATED NERVE FIBERS
CONGENETAL DISC ANOMALIES
HYLOID REMANENTS OVER THE OPTIC DISC
GLIAL TISSUE OVER THE OPTIC DISC
CONGENETAL FULLNESS OF OD ASSOCIATED WITH HYPEROPIA
Fundus photographs of various conditions causing psuedo disc
edema
Patho-physiolgy
Sub arachniod space around the optic nerve is continuous with sub arachniod space of the brain
When ever the CSF pressure increases it is transmitted to optic nerve …….this causes
Interruption of axoplasmic flow in the optic nerve and
venous congestion.
histopathology The of acute optic disc edema shows
1. axoplasmic stasis,
2. edema, and
3. vascular congestion
Peri-papillary hemorrhages are also seen
Physiological cup is filled by edema
Small blood vessels are engorged and tortuous
Neural retina is displaced
On electron microscopy
Engorgement of axons
axons are filled with swollen mitochondria
The tissue in front of the lamina cribrosa has become more voluminous due to swelling of the nerve fibers and vascular congestion. The tissue bulges towards the vitreous cavity and pushes the retina sideways
COMMON PRESENTING SYMPTOMS
HEADACHE:
EARLY MORNING
PROGESSIVELY WORSINING (PATIENT USUALLY PRESENTS IN HOSPITAL WITHIN SIX WEEKS)
MAY BE LOCALISED / GENERALISED
TENDS TO GET AGGRAVATED WITH BENDING, HEAD MOVEMENT OR COUGHING.
VOMITING:
SUDDEN , PROJECTILE , PARTIALLY RELIEVING HEADACHE.
CAN OCCUR AS AN ISOLATED FEATURE
CAN PRECEDE THE ONSET OF HEADACHE BY MONTHS (SPECIALLY IN FOURTH VENTRICULAR TUMORS)
DETERIORATION OF CONSCIOUSNESS:
USUALLY SLIGHT, LEADING TO DROWSINESS AND SOMNOLENCE
DRAMATIC DETERIORATION OF CONCIOUSNESS IS INDICATIVE OF BRAINSTEM DISTORSION AND TENTORIAL / TONSILAR HERNIATION.
VISUAL SYMPTOMS:
TRANSIENT VISUAL OBSCURATIONS (FLASHES, BLACKOUTS , GREYOUTS)
HORIZONTAL DIPLOPIA
CAUSED BY STRETCHING OF SIXTH NERVE OVER THE PETROUS TIP
VISUAL FAILURE (LATE BECAUSE OF SECONDARY OPTIC ATROPHY).
STAGES OF PAPILLEDEMA
1. EARLY
2. ESTABLISHED
3. CHRONIC
4. ATROPHIC
VISION MECHANICAL CHANGES
VACULAR CHANGES
NO VISUAL SYMPTOMS
VA -NORMAL
BLURRING OF MARGINS OF OD
HYPEREMIA OF OD
LOSS OF SPONTANEOUS VENUS PULSATIONS
VISION MECHANICAL changes VACULAR CHANGES
TRANSIENT VISUAL DISTURBANCE
ENLARGING BLIND SPOT
ELEVATED DISC WITH INDISTINCT MARGIN CIRCUMFRENTIAL
RETINAL FOLDS (PATON’S LINES)
SEVERE HYPERMIA
VENOUS TORTUOSITY AND DILATION
FLAME SHAPED HEMORRHAGES.
COTTON WOOL SPOTS
HARD EXUDATES, FOVEAL STAR
STAGE 2 ESTABLISHED
VISION MECHANICAL CHANGES
VASCULAR CHANGES
VA – IMPAIRED
VISUAL FIELD DEFECTS
GLIOSIS OF PERI-PAPILLRAY NERVE FIBRE LAYER
DECREASE IN HYPEREMIA ,COTTON WOOL SPOTS AND HEMORRHAGES
OPTICOCILLIARY SHUNTS
SHEATING OF BLOOD VESSELS
STAGE 3 CHRONIC PAPILLEDEMA
CHAMPAGNE CORK APPEARANCE
VISION MECHANICAL CHANGES VASCULAR CHANGES
SEVERELY IMPAIRED VA
SWELLING DECREASES
SECONDARY OPTIC ATROPHY
DIRTY GREYISH WHITE
INDISTINCT MARGINS
NUMBER AND CALIBER of blood vessels on the disc is reduced
STAGE 4 ATROPHIC SECONDARY OPTIC ATROPHY
Another grading of papilledema especially for
benign intracranial hypertension
Grade I papilledema is characterized by a C-shaped halo with a temporal gap in the peri-papillary nerve fiber layer
With Grade II papilledema, the halo becomes circumferential
Grade III papilledema is characterized by loss of major vessels AS THEY LEAVE the disc
Grade IV papilledema is characterized by loss of major vessels ON THE DISC
Grade V papilledema has total obscuration of all vessels of the disc.
it is extremely important to find out whether
Disc swelling present or not …..
And if there is disc swelling……is itpapilledema or optic neuritis .
•A careful history like hypertension, diabetes etc., should be taken. It should also include drug history particularly over dosage of Vitamin A, oral contraceptives, anti psychotics.
•A complete and thorough eye examination comprising of visual acuity, visual fields, refraction (with appropriate cycloplegic especially in children, and slit lamp examination of the fundus, vitreous, and macula).
Papilledema should be graded.
Difference between early papilledema and normal disc
1. Rule out pseudo-disc-edema by typical fundus appearance and other clinical signs
2. Spontaneous venous pulsations are present 80 % of the normal discs
3. For rest of 20 % do a FFA …..dye does not leak in normal discs
Difference between papilledema and other causes of disc edema
especially optic neuritis
history Headache, vomiting, Sudden loss of vision
VA normal Severely reduced
pain absent On movement of eye especially superiorly
laterality bilateral unilateral
pupil normal RAPD
Disc swelling +3 dioptres Less than 3 dioptres
Hemorrhages/ exudates More in established less
Visual fields Enlargement of blind spot Central or centraocecalscotoma
CT MRI SOL demyelination
Difference between papilledema and optic neuritis
INVESTIGATIONS
PERIMETRY:SHOW ENLARGED BLIND SPOT IN
ESTABLISHED STAGE AND ARCUATE FIELD DEFECTS IN LONG STANDING PAPILLEDEMA
B-SCAN:SHOWS RAISED OPTIC DISC
NEUROIMAGING (CT/MRI):TO LOCALIZE THE SPACE OCCUPYING
LEISION
FFAARTIRIAL PHASE:
CONGESTED CAPILLARIES ALONG
THE
NERVE FIBER LAYER.
AV PHASE HYPERFLOCESCENE OF DILLATED
CAPILLARIES, EXTENDING TO
ADJACENT RETINA.
LATE PHASE
MARKED HYPERFLORESCENCE
DUE TO LEAKAGE
A multidisciplinary approach is mandatory.
Ophthalmologist should guide the neuro-physicians/surgeons about the urgency of treatment by serially monitoring the
visual acuity
visual fields and
color vision
all these vital functions of eye change irreversibly when the papilledema progresses from established stage into chronic stage.
Neurophysician/surgeon should step up the anti-edema measures or intervene surgically at the earliest at this juncture
Treatment:
Treatment of the cause
And reduction of the increased CSF pressure by
Drugs
Shunt
CONCLUSION:
•Papilledema could be VISION AND LIFE THREATENING
•all doctors should be well aware about the importance of an eye examination in a case of headache when associated with visual disturbances like diplopia and vomiting.
Take home message
PERSISTANT HEADACHES SHOULD NOT BE TAKEN LIGHTLY
FUNDUS EXAMINATION IS MANDATORY IN CLINICAL EVALUATION OF SUCH PATIENTS.
TIMELY REFFERAL OF SUCH PATIENTS TO OPHTHALMOLOGY DEPARTMENT CAN BE LIFE AND VISION SAVING.
Thank you