1. OPTIC DISC SWELLING
Dr Abdul Munim Khan
Associate Professor & HOD
Ophthalmology
Dr Khawaja Abdul Hamid
Assistant Professor Ophthalmology
Mohtarma Benazir Bhutto Shaheed
Medical College Mirpur AJK
2. 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
3. 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.
4. 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
5. 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)
6. 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 EYE
BALL WAS NORMAL
•EXTRA OCULAR
MOVEMENTS WERE FULL
IN ALL DIRECTIONS OF
GAZE
Fundus : Bilateral Disc Edema
12. CT Scan
NON CONTRAST CT SCAN OF HEAD SHOWS
A 6x4cm LYTIC LESION IN BONY SKULL AT
LEFT PARIETO-OCCIPITAL REGION
CAUSING MODERATE COMPRESSION
ON 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.
13.
14.
15. Final diagnosis
Bilateral established papilledema as a
result of raised intracranial pressure,
because of left sided parieto-occipital space
occupying lesion.
29. 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.
30. All patients with papilledema should be
suspected of having intracranial SOL, unless
proven otherwise.
not all patients of intracranial SOL have
papilledema
31. 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.
32. 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.
41. 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
46. 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.
47. 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
48. 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
49. 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.
50. 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.
51. 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).
54. 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
55. 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
56. 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
63. it is extremely important to find out whether
Disc swelling present or not …..
And if there is disc swelling……is it
papilledema or optic neuritis .
64. •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.
65. 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
67. 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 centraocecal
scotoma
CT MRI SOL demyelination
Difference between papilledema and optic neuritis
68. 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
70. 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
72. 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.
73. 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.