That optic disc doesn’t look right…2

Papilloedema

The observed features include:

• swelling of the optic disc
• blurring of the disk margins
• hyperemia
• loss of physiologic cupping
• Flame-shaped hemorrhages and yellow exudates appear near the disk margins as edema progresses.

When observed in real time there may be obliteration of spontaneous venous pulsations (absent in 20% of normal people anyway).

Papilloedema itself is usually asymptomatic.

There may be episodes of transient, often bilateral visual loss (lasting seconds), precipitated by rising from a lying or sitting position as a result of intracranial pressure changes.

Otherwise the presentation reflects the underlying cause and symptoms of raised intracranial pressure (e.g. headache and vomiting, worse in the morning) may be present.

Papillitis (optic neuritis):

• pupilary reaction — RAPD present
• visual acuity — reduced
• colour vision — red desaturation
• visual fields — large central scotoma
• pain on eye movement — present
• localisation — usually unilateral
• fundoscopy — blurred disc margins

Papilloedema:

• pupilary reaction — normal
• visual acuity — normal (transient loss)
• colour vision — normal
• visual fields — large blind spot, peripheral constriction
• pain on eye movement — present
• localisation — usually bilateral
• fundoscopy — blurred disc margins, no venous pulsation

Watch this RootAtlas video to see what spontaneous venous pulsations look like on funduscopy.

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)

Optic atrophy

Atophy is a misnomer — it is not a result of disuse!

A pale insipid optic disc (loss of the normal yellowish colour), with absence of normal physiological cupping.

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

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

The optic disc is not truly swollen — the characteristic findings include:

• Vessels overlying the disc are not obscured
• the disc is not hyperemic
• surrounding nerve fiber layer is normal.
• spontaneous venous pulsations are usually present.

Further investigation may still be required to rule out raised intracranial pressure.

• Beck RW, Cleary PA, Trobe JD, Kaufman DI, Kupersmith MJ, Paty DW, Brown CH. The effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. The Optic Neuritis Study Group. N Engl J Med.  1993 Dec 9;329(24):1764-9.  PMID: 8232485.
• The 5-year risk of MS after optic neuritis. Experience of the optic neuritis treatment trial. Optic Neuritis Study Group. Neurology. 1997 Nov;49(5):1404-13. PMID: 9371930.
• Patel V, Oetting TA. Optic Nerve Drusen: 19 year-old female with blurred vision. EyeRounds.org
• Sellebjerg F, Nielsen HS, Frederiksen JL, Olesen J. A randomized, controlled trial of oral high-dose methylprednisolone in acute optic neuritis. Neurology. 1999 Apr 22;52(7):1479-84. PMID: 10227638.
• Ehlers JP, Shah CP, Fenton GL, Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease Lippincott Williams & Wilkins
• NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide. [Free PDF]