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Papilloedema

  • Papilloedema refers to bilateral optic disc swelling due to raised intracranial pressure (ICP)

    • doesn't refer to all optic disc swelling - those caused by raised ICP only​

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Clinical appearance

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  • Indistinct optic disc borders

  • Pale optic disc - loss of healthy pink colour

  • Obscuration of blood vessels crossing the optic disc margin

  • Exudates may be visible over the optic disc surface

    • may also see cotton wool spots and fllame haemorrhages

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Causes

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  • Papilloedema implies space occupying lesion in brain until proven otherwise

    • this includes:

      • brain tumours - benign or malignant (e.g. suprasellar meningioma)

      • intracranial haemorrhage

      • trauma leading to haematoma and/or oedema

    • ​​space occupying lesions can press on the optic chiasm and/or pituitary gland​

      • this blocks the drainage of cerebro-spinous fluid (CSF) that surrounds the optic optic nerve

      • results in swollen optic disc appearance

  • Other causes of papilloedema:

    • idiopathic intracranial hypertension

      • commonest cause of papilloedema

      • typically affects obese women aged 20-30 years

      • diagnosis of exclusion - normal neuroimaging, no other cause of raised intracranial pressure identified

      • lumbar puncture will show elevated opening pressures - no other abnormalities

    • tumours causing increased CSF production

    • disease causing blockage of CSF drainage

  • May be asymptomatic from visual perspective, but may have symptoms associated with raised ICP e.g. headaches worse on lying down, transient visual obscurations, nausea and vomiting, tinnitus - prompt you to look at optic nerves to look for swollen optic nerve

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Clinical features

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  • Transient reduced visual acuity

    • typically last seconds at a time

  • Diplopia (double vision)

  • Visual field defects

  • Headache - as a result of increased ICP

    • usually worse on straining e.g. coughing, bending down​

    • may be accompanied by nausea / vomiting​

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Investigations

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  • In any case of bilateral disc swelling, must perform neuro-imaging (CT or MRI head) to exclude space-occuping lesion

    • need to exclude life-threatening intracranial lesions; may require neurosurgery

  • Lumbar puncture to assess opening pressures - if raised, suggests raised ICP

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Treatment

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  • Treatment depends on underlying lesion

    • treatment for IIH: weight loss advice, acetazolamide, lumbar-peritoneal shunting​

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References

  • Denniston, A. K. O. and Murray, P. I. (eds) (2018) Oxford handbook of ophthalmology. 4th edn. London, England: Oxford University Press (Oxford Medical Handbooks). doi: 10.1093/med/9780198804550.001.0001.

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