Optic disc abnormality DDx

Overview

The important optic disc abnormalities are: papilloedema, papillitis and optic atrophy

• Papilloedema – swelling of the optic disc with blurring of the disc margins, hyperaemia and loss of physiologic cupping. Flame-shaped hemorrhages and yellow exudates appear near the disc margins as edema progresses. There is loss of spontaneous venous pulsations (but this is absent in 20% of people anyway).
• Papillitis – characterised blurred disc margins, that is usually unilateral, associated with decreased visual acuity and red desaturation, a central scotoma and relative afferent pupillary defect and pain on eye movements.
• Optic atrophy – pale insipid optic disc (loss of the normal yellowish colour), with absence of normal physiological cupping.

Causes

Papilloedema

intracranial

• space-occupying lesions (e.g. neoplasms, trauma, infection, and vascular causes)
• benign intracranial hypertension (trauma, drugs, idiopathic, Addisons, sinus thrombosis)
• central venous sinus thrombosis
• meningoencephalitis

CSF

• hydrocephalus – obstructive, communicating (production vs. absorption of CSF)
• high CSF protein — e.g. Guillain-Barre Syndrome

extracranial

• central retinal vein occlusion (CRVO)
• retro-orbital mass
• hypertension (grade IV)

Pseudopapilledema mimics papilloedema and may result from the presence of optic disc drusen or a congenitally anomalous disc.

Papillitis

• multiple sclerosis
• familial
• idiopathic
• inflammation
  • viral — e.g. infectious mononucleosis, herpes zoster, viral encephalitis
  • childhood infections or vaccinations — e.g. measles, mumps, chickenpox
  • Granulomatous inflammations — e.g. tuberculosis, syphilis, sarcoidosis, cryptococcus
  • Contiguous inflammation of the meninges, orbit, or sinuses.

The differential includes optic neuropathies such as:

• toxic optic neuropathy — e.g ethambutol, chloroquine, nicotine, alcohol
• metabolic optic neuropathy — vitamin B12 deficiency
• ischemic optic neuropathy — diabetes mellitus, giant cell arteritis, atherosclerosis
• compressive optic neuropathy — e.g. orbital tumour, intracranial mass

Optic atrophy

Optic atrophy may be the end stage of:

• chronic papiloedema
• chronic optic neuritis
• glaucoma
• optic neuropathies (e.g. toxic, metabolic, ischemic and compressive)
• familial, e.g. retinitis pigmentosa

References and Links

LITFL

• Ophthalmology Befuddler 009 — That optic disc doesn’t look right

Journal Articles and Textbooks

• Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition), Lippincott Williams & Wilkins 2008.

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

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