DISC EDEMA

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DISC EDEMA

• Prof. Vasudev Anand Rao

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CAUSES

• UNILATERAL
• Papillitis
• Anterior Ischemic optic neuropathy
• Neuroretinitis
• Papillophlebitis
• Ischemic CRVO
• Anterior compressive optic neuropathies
  (orbital tumors)
• Infiltrative optic neuropathies
• Ocular hypotony
• Foster-Kennedy syndrome

• BILATERAL
• Papilledema
• Hypertension
• Diabetic papillopathy
• Advanced Graves disease
• Cavernous sinus thrombosis
• Carotid cavernous fistula
• Leber hereditary optic neuropathy

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PAPILLEDEMA optic disc swelling

• Conventionally the term refers to hydrostatic
  non-inflammatory optic disc swelling that results
  from raised intracranial tension.

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ETIOLOGY

• 1. Intracranial space occupying lesion
• neoplasm (location of the tumor is more important
  than size)
• abscess/inflammatory mass
• hemorrhage/infarct
• A-V malformation
• 2. Obstruction of ventricular system
• 3. Cerebral edema
• 4. Impaired CSF absorption by arachnoid villi
• Meningitis
• Raised venous pressure
• SAH/trauma
• Communicating hydrocephalus
• 5. Severe systemic hypertension
• 6. Idiopathic (pseudo tumor cerebri)
• 7. Decreased size of cranial vault
• Craniosynostosis
• Thickening of skull
• 8. Hypersecretion of choroids plexus tumor

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CLINICAL FEATURES

• SYMPTOMS
• Ocular
• Visual acuity-normal in early ,decreased when
  established and grossly affected when atrophic
• Amaurosis fugax(spasm of arteries)
• Central vision affected late(selective loss of
  peripheral
• neurons)
• Diplopia(assoc. 6th cranial nerve palsy in raised
  ICT)
• General
• Headache (bifrontal/occipital) more in the
  morning,
• aggravated by coughing straining
• Projectile vomiting
• Loss of consciousness/ focal neurological deficits

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CLINICAL FEATURES

• SIGNS
• PUPILLARY REACTION -normal until optic atrophy
  sets in
• 2. FUNDOSCOPY
• EARLY PAPILLEDEMA
• Hyperemia/elevation of disc
• Blurred margins
• Loss of SVP
• Superficial hemorrhage

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CLINICAL FEATURES

• ESTABLISHED/FULLY DEVELOPED PAPILLEDEMA
• Engorged tortuous veins
• Numerous flame shaped hemorrhages
• Cotton wool spots, hard exudates
• Peripapillary edema (patons lines)
• Retinal folds/macular star

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CLINICAL FEATURES

• CHRONIC/VINTAGE PAPILLEDEMA
• Optic disc pale elevated (champagne cork
• appearance)
• Disc obliterated
• Opticociliary shunts

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CLINICAL FEATURES

• ATROPHIC PAPILLEDEMA
• Pale grey disc with reactive gliosis
• Narrow and sheathed vessels
• Retina shows pigmentary changes and
• choroidal folds

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CLINICAL FEATURES

• 3. FIELD CHANGES
• Early-normal
• Established-enlargement of blind spot
• Chronic-peripheral constriction
• End stage-total loss
• 4. FLUORESCEIN ANGIOGRAPHY
• To differentiate true and pseudopapilledema
• Dilatation of surface capillaries and leakage of
  dye
• in the late phase
• 5. NEUROIMAGING
• Features of raised ICT-silver beaten appearance
  with erosion of posterior clinoid process and
  dorsum sellae
• Cause of raised ICT may be identified.

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UNILATERAL PAPILLEDEMA

• Asymmetric
• Foster Kennedy syndrome
• Seen in patients with frontal lobe/olfactory
  lobe tumors, meningiomas of olfactory
  groove/sphenoidal wing, characterized by optic
  atrophy on the side of the tumor caused by direct
  pressure on the nerve and papilledema on the
  opposite side because of raised ICT.
• Prior optic atrophy, congenital abnormality in
  disc, high myopia

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PSEUDOTUMOR CEREBRI

• Or Benign Intracranial hypertension
• Defined by 4 criteria
• Increased intracranial pressure
• Normal or small ventricles
• No evidence of intracranial mass lesion
• Normal CSF composition
• Usually idiopathic seen in young obese women

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ETIOLOGY

• Endocrine causes
• Addisons disease
• Hypoparathyroidism
• Hyperthyroidism
• Hypothyroidism
• Menopause
• Menarche
• Pregnancy

• Drugs
• Vitamin A
• Tetracycline
• Steroids
• OCP
• Phenytoin
• Indomethacin
• Growth hormone
• lithium

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TREATMENT

• Weight loss
• Acetazolamide
• Lumbar puncture
• Surgical decompression (ventriculo-peritomeal
  shunt)

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DIFFERENTIAL DIAGNOSIS - Ocular
1. PAPILLITIS
Papillitis Papilledema
1.Presentation U/L B/L
2.Vision Sudden loss Unimpaired initially
3.Pupil RAPD present RAPD absent
4.Media Hazy near posterior vitreous Media clear
5.Pain/tendeness of eyeball Present Absent
6.Hemorrhages/exudates Less More(in established)
7.Disc swelling 2 to 3D gt3D
8.Field defects central/centrocaecal scotoma Enlargement of blind spot, later peripheral constriction.
9.X-ray skull Normal Silver beaten appearance, erosion of dorsum sellae,post clinoid
10.CT/MRI Demyleinating ICSOL etc.
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DIFFERENTIAL DIAGNOSIS - Ocular
2. PSUEDOPAPILLEDEMA

• Hypermetropia
• Crowded nerve fibers at disc. More in
  children, no enlargement of blind spot
• Astigmatism
• Optic nerve head drusen
• Calcium containing refractile bodies within
  substance of optic nerve head. Seen in USG.
  Autofluorescence
• Hazy media

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DIFFERENTIAL DIAGNOSIS - Ocular
3. AION/LHON/TOXIC AMBLYOPIAS 4. OCULAR
HYPOTONY Effusion from choroidal vessels 5.
RAISED INTRAOCULAR PRESSURE Obliteration of
peripapillary vessels by raised IOP 6. CRVO
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OPTIC NEURITIS Inflammation of the optic
nerve
ETIOPATHOGENESIS

• IDIOPATHIC
• DEMYELINATING (Always Retrobulbar)
• Isolated
• a/w multiple sclerosis
• neuromyelitis optica
• schilders disease

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ETIOPATHOGENESIS

• INFECTIOUS AND PARAINFECTIOUS
• LOCAL
• Orbital cellulites
• Sinusitis
• Teeth, tonsil
• Meninges, brain or base of skull.
• SYSTEMIC
• VIRAL-measles, mumps, rubella, chickenpox,
  herpes, CMV and EBV.
• BACTERIAL-T.B,syphilis,cat scratch disease,lymes
  
• FUNGAL-cryptococcosis,histoplasmosis
• PARASITImalaria,pneumocystis,toxoplasma,toxocara,c
  ysticercosis
• VACCINESBCG,DPT,TT,HepB,variola and influenza

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ETIOPATHOGENESIS
4.IMMUNE RELATED LOCAL Uveitis, sympathetic
ophthalmitis. SYSTEMIC sarcoidosis, Wegeners
polyarteritis nodosa, SLE etc. 5.METABOLIC
Anemia Diabetes Starvation 6.DRUGS AND TOXINS
INH, ethambutol, etanercept, INFa, tobacco,
alcohol, quinine.
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CINICAL FEATURES
Commonly unilateral, more in females and mean age
is 30-35 yrs. SYMPTOMS Triad of Loss of
central vision Eye pain Decreased colour
vision Other Altered perception of moving
objects Worsening of symptoms with elevation of
body temperature(uhthoff sign)
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CINICAL FEATURES

• SIGNS
• Decreased visual acuity
• Tenderness
• Marcus gunn pupil (RAPD)
• Decreased colour vision and contrast sensitivity
• Visual field defects classically
  central/centrocaecal scotoma
• but other defects can also occur
• Fundus changes
• 1. Papillitis edema, hyperemia, blurred margins,
  dilated
• tortuous vs, few exudates and vitreous haze
• 2. Retrobulbar neuritis normal
• 3. Neuroretinitis macular star with exudates
• VEP-Delayed latency and decreased amplitude
• FAG to differentiate from other causes-dilated
  and telangiectatic vs with leak from capillaries

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CINICAL FEATURES
Field defects in optic neuritis
Papillitis
Neuroretinitis
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INVESTIGATIONS
To determine cause for optic neuritis 1.Complete
Hemogram 2. CRP, ESR, Mantoux 3. VDRL 4.
Serology-ANA, Toxoplasma, Lymes 5. PNS X-ray,
chest x ray(sarcoidosis) 6. X ray skull, CT 7.
MRI(demyleinating plaques-2 or more predictive of
deveplopment of MS) 8. Lumbar puncture-CSF
pleocytosis and oligoclonal bands
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MRI scan showing demyelinating optic neuritis
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TREATMENT

• 1. ONTT Regimen - Intravenous methylprednisolone
  250mg q 6 h for 3 days followed by
• Oral prednisolone 1 mg/kg/day for 11 days,
• tapered with 20mg on 15th day and 10mg on 16th
  and 18th day
• 2. Posterior sub-tenon injection of triamcinolone
• 3. Vitamin B12
• 4. Treatment of identifiable cause

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Ischemic optic neuropathy

• Infarction of prelaminar or laminar portions of
  optic nerve caused by occlusion of posterior
  ciliary artery.
• Seen in gt50 yrs.
• H/s/o giant cell arteritis or predisposing
  factors like DM/HT
• Pale swollen disc with splinter hemorrhages
• Altitudinal scotoma
• Classified as
• Arteritic Non-Arteritic

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Clinical Features
Features Arteritic AION Non Arteritic AION
Age gt60yrs 40-60yrs
Sex Ratio FgtM FM
Vision loss Severe Moderate (gt6/60)
Laterality Fellow eye affected in 95 within days to wks Fellow eye affected in lt30 in months or yrs
Optic disc Pale edema, may be sectoral Hyperemic or pale edema
Assoc. Signs Scalp tenderness, palpable tender, non-pulsatile temporal artery Assoc. HT 40, DM 24 Shock, nocturnal hypotension
ESR gt40 mm in 1st hr 20-40mm in 1st hr
FAG Disc and choroidal filling delay Disc filling delay
Treatment IV methylprednisolone ? Levadopa-carbidopa
Prognosis Poor Improvement in upto 43
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• THANK YOU