Papilledema could be
Though there are
exceptions, the public and all doctors are well aware about the
importance of an eye examination in a case of headache when related to
visual work or when associated with visual disturbances like diplopia
When often patients
visit ophthalmologists for headache, we rule out other causes of
headache like refractive errors, ocular muscle imbalance, ocular
inflammation and glaucoma in them .Later we specifically look at the
optic disc for obtaining an insight to the cause of headache.
When it is a case of
disc edema it is extremely important to know whether it is true disc
edema or pseudopapilledema and whether we are dealing with a case of
optic neuritis .
A careful history
like hypertension, diabetes etc., taking into account the various
causes should be elicited. It should also include drug history
particularly overdosage of Vitamin A, oral contraceptives, anti
psychotics and others.
A complete and
thorough eye check up comprising of visual acuity, visual fields,
refraction (with appropriate cycloplegic especially in children, and
slit lamp examination of the fundus, vitreous, and macula.
We should also have
an idea of the stage of papilledema.
angiography (FFA) will show leak in cases of disc edema. This test
should be carried out only when doubtful as it only helps in
differentiating true from pseudo papilledema but not optic neuritis
cause is ruled out, an opinion by neurologist or neurosurgeon should
be sought to establish the diagnosis.
MRI of the
brain with or without contrast should be carried out.
Guarded LP for
C.S.F analysis or for reduction of ICT during dire emergency with
If papilledema is
due to intracranial cause then anti-edema measures and the underlying
causes have to be detected and treated ( ATT for tuberculoma,
withdrawal of oral contraceptives, withdrawal of antipsychotics,
removal of intracranial SOL or shunting of associated hydrocephalus
In benign ICT-Acetazolamide
is the drug of choice especially the sustained release variety due to
lesser side effects because of BD,OD or AD dosage.Regular variety has
to be consumed 4 times a day and side effects like paraesthesia are
more and reduces the compliance.Liver function tests and hemogram have
to be done periodically. Most of the cases spontaneously resolve but
some of them may continue to have headache and visual loss. When
visual deterioration is detected despite adequate antiedema measures,
a lumbo-Peritoneal or subtemporal decompression is done by the
Lately, Optic Nerve Sheath
Fenestration is preferred and carried out by a team of E.N.T,
Neuro and eye surgeons.
Transnasal endoscopic approach would be
preferable these days because both optic nerve sheaths can be tackled
in the same sitting, and the Optic canal can be directly
approached and optic nerve sheath visualized. The risks are infection
and transfer of heat while working with burr in the vicinity of optic
nerve. Continuous irrigation with water will be of help. Appropriate
and adequate coverage with antibiotics will reduce chances of
ophthalmologist in management during the course of papilloedema:
Combined team work
and clear communication and cooperation amongst the treating doctors
will do wonders for the patient. A multidisciplinary approach in fact,
should guide the neurophysician and neurosurgeons by carefully
monitoring the visual acuity and color vision by Ishihara chart.
However when patient has difficulty in perceiving colors like before,
he / she is asked to report promptly.
monitoring–The appearance of overall peripheral constriction in serial
autoperimetry provides more valuable information rather than the
fundus picture for florid stage going into chronic and atrophic.
Visual acuity decreases after that. It is not advisable to wait until
then. It could denote the ?commencement of irreversible damage of the
axons in the optic nerve –This should ring an alarm and the
ophthalmologist should warn the neuro faculty about the urgency of
the situation to step up the antiedema measures or intervene
surgically at the earliest.
The author would
like to share some of the experiences with illustrating cases.
Case – 1 :
A fourteen year
old female with complaints
of headache for one year had consulted several doctors. A diagnosis of
depression was made. Having got no relief she finally came down to
Chennai. The neuro surgeon subjected her to investigations.
MRI showed SOL. Stereotactic biopsy
and HPE confirmed it as a case of tuberculoma.
examination showed –Right eye BCVA 6/18, 16/16 color vision ,disc
edema and hyperemia with peripapillary sheathing and macular
exudates and normal visual fields. In the left eye the vision was
hand movements, and mild pallor of the disc.
picture remained status quo with ATT and anti-edema measures.
Ethambutol was deliberately avoided for its neuro toxicity on the
After that the
right eye began to show peripheral constriction despite IV
mannitol etc. Only few days later the VA dropped from 6/18 to HM
in RE and no PL in LE (picture B).
showed decrease of perilesional edema .
discussions, a decision to perform trans nasal endoscopic
decompression bilaterally in the same sitting under GA was made
and carried out after explaining the risk of loosing vision and
possibility of developing infection. At the end of the surgery CSF
was let out.
picture-the optic nerve sheath being fenestrated.
Though vision improved transiently
to CFCF for 2 days she was PL –VE for 2 months. She then regained
vision in Right eye to 6/6, visual fields full and could pursue
her normal life and studies.
ONSF can be also
be done transconjunctivally by the ophthalmologist on one side at
a time. Surgery on one optic nerve can reduce the pressure on
contralateral optic nerve .But T / N endoscopy was adopted because
as mentioned earlier it gives best access to the optic canal with
least injury to the optic nerve. While tackling the outer part of
canal bone with burr, the heat generated can be lessened by
continued irrigation. The inner part should be curetted.
Mitomycin - C
application on the optic nerve sheath before the fenestration has
found to maintain the patency of the fistula.
ONSF is nowadays
being recommended for secondary causes of increased
(A) visual fields of RE
fields of LE
Case - 2:
A 15 yr old female
had headache for 1 yr .Ophthalmic examination was done elsewhere only
at the beginning. Since it was found to be normal she used to take
analgesics for relief. Finally when she developed vomiting and swaying
gait, choroidal plexus tumor in the CPA was diagnosed .Despite
surgical, radiotherapy and antiedema measures, her papilledema rapidly
progressed and VA deteriorated drastically in a week’s time .She is
now with only CFCF angular in RE and no PL in LE.
A word of
If the SOL is a
choroidal plexus tumor, the rate of progression of papilledema is
alarmingly rapid and accelerated so much so that the patient goes from
florid to chronic and atrophic in no time and looses vision unless
timely and appropriate management are rendered.
for various intracranial space occupying lesions, ICT can raise due to
cerebral edema. Concomitant anti edema measures will reduce the burden
on the optic nerves.
A 30 yr old female
was referred as a case of papilledema by neuro surgeon for
neuroophthalmic examination. Slit lamp examination showed mild
bilateral anterior uveitis. Sarcoidosis was suspected and confirmed.
The disc edema and uveitis responded to oral prednisolone. Topical
steroids and cycloplegic drops were also given. It was a case of B /
L disc edema due to sarcoidosis.
A 55 yr old male was
referred to as a case of papilledema for neuroophthalmic examination.
He was being investigated for brain metastasis at a tertiary care
hospital. His BP was recorded normal all through out by staff nurse.
He was previously treated for malignancy in the neck successfully. But
fundus examination showed arterial attenuation in addition to disc
edema. The BP was personally recorded and found to be 220/160 mm Hg.
MRI and CSF analysis were normal. It was a case of grade - 4
A 40 yr old female
was referred for headache to us by medical oncologist. She was a known
case of Recurrent B Cell Lymphoma of the lungs. O / E she was found to
have neovascular glaucoma in LE . Fundus examination revealed partial
block of both central retinal arteries and optic discs had blurred
margins. Media was hazy in Left Eye. There was both central retinal
artery and vein occlusion in the Right Eye. A diagnosis of
infiltrative optic neuropathy was made. MRI of brain showed optic
nerve thickening correspondingly. Radiotherapy helped in resolution of
edema and improvement of vision.
A 10 yr old girl
complained of severe headache and vomiting for few days . Her
ophthalmic examination showed papilloedema in both eyes. Careful
history revealed that the child was taking Vitamin A 50000 IU everyday
for the preceding 3 months though she was advised the treatment only
for few days. Discontinuation of Vit A reversed papilledema and
relieved the symptoms. Similarly 40 yr old female from Calcutta, a
teacher by profession was found to have papilledema and benign ICT.
The antidepressant she was taking was the causative factor. She was
alright in few days after she stopped taking the medicine.