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ByProf. K. Vengala Rao
TRUE EDEMA OF O.D.
DUE TO RAISED I.C.P.
Definition
Formen of monroe
3rd VENT
Aqueduct of Syluius
4th VENT
Foramina of Majendi & Lushka
S.A. SPACE
VENOUS SYSTEM THROUGH ARACHNOID VILLI
C.S.F. : FORMED BY CHOROID PLEXUS
INFANTS : LESS THAN 80 MM OF WATER
CHILDREN : 90 MM
ADULTS : 210 MM
CSF Pressure
Dilatation of Ventricles due to Raised I.C.P.
Communicating Hydrocephalus
Non communication Hydrocephalus
Obstruction to C.S.F. outflow
HYDROCEPHALUS
Systemic : Headache
Nausea and Vomiting
Deterioration of Consciousness
Clinical features of raised ICP
T.V.O. lasting few seconds
Horizontal Diplopia due to 6th Palsy
Visual Failure due to Post Papilloedema optic atrophy
Visual symptoms of raised ICP
1) Obstruction of ventricular systemCongenital and Acquired =hydrocephalus
2) S.O.L. - Sub Arachnoid Haemorrage3) Impairment of C.S.F. absorption
Meningitis, S.A.H. Trauma4) I.I.H. - Pseudo Tumour Cerebri5) Trauma - Diffuse Cerebral Edema6) Severe Systemic H.T.7) Hypersecretion :Tumours of choroidal Plexus8venous sinus thrombosis
Etiology of papilledema
A) Early Acute papilledema
B) Established
C) Chronic Chronic Papilledema
D) Atrophic
Classification of Papilloedema
No Visual SymptomsHyperemia of O.D.Blurring of R.N.F.L.Swelling of O.D.Blurring of O.D.Flame shaped
HaemorrhagesAbsence of Venous pulseVenous Dilatation
Early Papilloedema
Capillary Dilatation
Early sign
No Hyperemia - No Papilloedema
Hyperemia
Blurring of Peri – papillary R.N.F.L.
Superficial leniar light reflex loss
Swelling of O.D.
First seen near superior and inferior poles
Hyreh – 1st sign is swelling
Blurring of Margins
No Value as single sign
Nasal, Superior, Inferior, Temporal
Peri – papillary R.N.F.L. Haemorrages
important Sign
Rupture of Dilated Capillaries
Loss of Venous Pulse
I.C.P. more than 200 mm
20% have no venous pulse normally
Not a definite sign
Dilatation of Retinal veins
not an early sign
Single finding is not diagnostic
Frequent observation of the patient
C.T or M.R.I. If there is doubt
Summary of Early Papilloedema
More disc swelling
Venus dilatation
Splinter hemorrhages on
O.D. and Retina
M.A., Capillary Dilatation on O.D.
Vessels obscured by
Swollen N.F.L.
Soft exudates
Patton’s lines
Hard exudates - macular fan
Sub Hyaloid Haemorrages
Fully developed Papilloedema (Established)
Haemorrages and exudates resolve
Cup obliterated
Disc becomes gray
Hard exudates on the disc
N.F.L. atrophy
Chronic Papilloedema
Edema subsides
Atrophy of O.D.
Narrowing and sheathing of vessels
Choroidal folds
May occur in months or years
Optico ciliary shunts
Peripheral field loss
Post Papilloedemic Optic Atrophy
Usually bilateral
Unilateral papilloedema may occur
Congenital anomalies
Brain abscess
Damage to Optic Tract causes homonymous hemianopia with atrophy of nasal fibres causes band atrophy. In such cases if Papilloedema occurs it is seen in the upper and lower parts of the OD only. TWIN PEAK PAPILLEDEMA
Optic atrophy in one eye due to any cause does not develop papilloedema in that eye.
Unilateral or Asymmetric Papilloedema
Frontal lobe and Olfactory groove tumorsOptic atrophy on one sidePapilloedema on other sideOptic atrophy is due to pressure on O.N.Pseudo foster Kennedy syndromeacute A.I.O.N in one eye & old A.I.O.N in other eye
Foster Kennedy Syndrome
Foster Kennedy Syndrome
A case of Foster Kennedy syndrome with unilateral disc swelling in the left eye and relative pallor in the opposite right eye due to a meningioma.
The CT showed a large meniningioma
The visual field showed a defect on the sideof the tumor. The opposite eye showed only an enlarged blind spot from disc swelling
Pseudo foster Kennedy syndrome
The most common cause of a Pseudo Foster Kennedy syndrome is old AION in one eye and a new AION in the other eye.This man has a case of pseudo-Foster Kennedy syndrome with unilateral disc swelling due to AION and the other eye has optic atrophy due to a previous bout of AION.
1) Direct ophthalmoscopy with red free light
2) Indirect
3) If there is doubt
a) F.F.A.
B) Ultrasound
c) O.C.T
d) C.T. or M.R.I.
e) L.P. if there is no mass lesions
Diagnosis
Capillary dilatation on O.D.
Dye leakage
Micro aneurisms
Late Dye leakage beyond O.D. margins
FFA
Pseudo – papilloedemaCongenital anomalies of optic disk
M.N.F O.D.DRUSEN TILTED disk Disk hypoplasia Hyaloid remnants on OD Congenital fullness due to small scleral canal HYPERMETROPIC O.D
Differential Diagnosis
O.D.D accounts for most cases of pseudo edemaO.D is not hyperemic, surface micro vasculature is not dilatedBlurring of disc margins is due to axoplasmic stasis in the axons deep in the optic disk.This causes hazy appearance of disk marginBut not the vesselsAnomalous brancing of retinal vesselsPeri papillary R.P.E dispersionDisc margin has scalloped appearance
OPTIC DISC DRUSEN
Small calcific concretions present in 1 – 2 % of O.NAutosomal dominant transmission Bilateral could be asymmetricalMay progress ,usually asymptomaticOccasionally T.V.OBuried Drusen may resemble disk edemaMay cause peripheral field defectsAcute vision loss due to A.I.O.NAcute vision loss from peri papillary C.N.V.MNo treatment for O.D.D
OD DRUSEN contd...
Funds examinationAuto fluorescenceC.T scan of orbits without contrastUltrasound B ScanF.F.A
Diagnosis of OD DRUSEN
OD Drusen
CT Scan B Scan Fundus
Auto – fluoresceins red free photo
Bilateral ONH hypoplasia
Bilateral inferior field defects
A) Tilted Optic nerves in high myope patient
MNF
B) Bi – temporal defects
OD oedema due to other causes
1.I.O. inflammation2.Diabetic Papillopathy3.Optic peri Neuritis4.Infiltrative neuropathy5.Compressive Neuropathy6.A.I.O.N. And Papillitis7.Hypertension8.Infiltration of optic nerve9.L.H.O.N
True PseudoO.D elevated elevatedHyperemic yellowish whiteIncreased capillaries on O.D anomalous largeAnd venous dilatation vessels with multiple
branchesCentral cup: present absentHaemorrhages, exudates present absent
Differentiation between true and Pseudo - Papilloedema
O.D.E due to O.N.P Papilledema1. Unilateral Bilateral2. Decreased V.A Normal V.A3. Decreased C.V Normal C.V4. Field defects: central Enlarged B.S., nasal
Arcuate, altitudinal defect, constriction5. Isolated or underlying Symptoms of raised
I.C.P Disease 6th cranial nerve palsy
pulsatile tinnitus; T.V.O.6. No neurological symptoms present
Differentiation between ODE due to other causes from Papilloedema
Develops from hours to months
Resolution depends on
how fast the I.C.P. is reduced
Development
More rapid - more serious
More severe - Worse Prognosis
Narrow arteries - Bad prognosis
Pallor - Bad prognosis
Loss of central vision, loss of field
Loss of colour vision or early parameters for loss of vision
Prognosis for Vision
Abnormal protrusion of O.D.
Lateral displacement of retina
Folds of posterior retinal layers
Haemorrages
Focal necrosis of N.F.
Axonal swelling
Distended S/A space
Pathology
1) Uncertain
2) Patency of Meningeal spaces is a must
3) Blockage of Meningeal spaces - no Papilloedema
4) Optic atrophy - no Papilloedema
5) Abnormal axonal transport
Pathogenesis
Axoplasmic Transport
Orthograde – Retrograde
Fast Component – 500MM per Day
Slow Component – 2MM per Day
Pathogenesis (contd)
Obstruction to axoplasm transport I.C.P. transmitted Into S.A. Space of O.N This Obstructs axoplasm transport Slow Component affected in Papilledema Rapid Component in Ischemia, Inflammation Rapid component important for Synaptic transmission Slow component for nutrition
Pathogenesis (Contd…)
Non Visual: VISUALHeadache FlashesVomiting T.V.O in one or both eyes
precipitated by change of postureBradycardia Untreated papilledema leads to
visual lossLoss of Consciousness Central V.A is normal until lateRigidity, Mydriasis and Field changes : enlarged blind LR Paralysis spot, nasal defects and later
central 300 field is involved
Symptoms and Signs
T.V.O. - Few seconds on change of posture
cause - distended 3rd ventricle
Ischemia of O.N.
Hippocanpal Herniation
B.S. Enlargement
Arcuate scotoma
Nasal defect
Peripheral contraction
Field defects
Papilledema is an emergencyPapilledema is an emergency
Workup : look for underlying neurological disease.Workup : look for underlying neurological disease.
Visual functionVisual function
Check blood pressureCheck blood pressure
Refer to neuro centreRefer to neuro centre
Responsibility of Ophthalmologist
Neuro imaging is an emergency
M.R.I of brain with contrast is ideal
C.T scan with out contrast is useless
C.T detects only i/c hamorrhage, hydrocephalus and large S.O.L
Normal brain M.R.I suggests Meningeal process, venous hypertension and I.I.H
L.P with C.S.F opening pressure and C.S.F analysis should be performed
Evaluation of patient with papilloedema
Subtentorial mass causes papilloedema often
Supratentorial mass - Papilloedema Less frequent
Posterior cranial fossa tumors cause Papilloedema more often
80 % of brain tumors cause Papilloedema
Gliomas cause Papilloedema in 76 %
IC mass and Papilloedema
Lars frisen grading Grade 0 increased IC pressure very little If any disc swelling is seen Stage 1; C shaped blurring of nasal, superior and
inferior borders Stage 2; elevation of disc margin 360 Blood vessels at disc margin not obscured Stage 3;elevation of entire disk with partial Obscuration of retinal vessels at disc margin
Grading of papilloedema
Stage 4; complete obliteration of cup Complete obscuration of some vessels On the surface of the disc Small dilated capillaries on the disc Haemorrhages and N.F.L infarcts Stage 5; Dome-shaped appearance with all
vessels being obscured. (Sometimes called "champagne cork" swelling ? because of its dome shape.)
Grading of papilloedema (contd…)
Grading Papilledema: Stage 0GRADING PAPILLEDEMA We grade papilledema in order to tell us how severe it is. The most sensible grading scheme has been provided by Lars Frisen.
STAGE 0: This woman had documented increased intracranial pressure of 340 mm water. Very little if any disc swelling is seen.
Stage 1 = C-shaped blurring of the nasal, superior and inferior borders. Usually the temporal margin is normal.
Also notice the chorio – pretinal folds (arrows)that eminate toward the macula (M)
Stage 2 = Elevation of the disc margin 360 degrees. Since the blood vessels at the disc margin are not swollen or obscured, this disc could be mistaken for pseudo-papilledema
Stage 3 = Elevation of the entire disc with partial obscuration of the retinal vessels at the disc margin. Here the vessels are partly obscured and make the development into stage 3 easier to call.
Stage 4 = Complete obliteration of the cup and complete obscuration of at least some vessels on the surface of the disc. There may be small dilated capillaries on the disc that resemble telangiectasia. It is not the NFL infarcts or hemorrhages but the obscuration of the vessels themselves that makes this disc stage 4.
Stage 5 = Dome-shaped appearance with all vessels being obscured. (Sometimes called "champagne cork" swelling ? because of its dome shape.)
Papilloedema is a neurological emergency.Papilloedema is a neurological emergency.
Responsibility for diagnosis rests with the Responsibility for diagnosis rests with the Ophthalmologist.Ophthalmologist.
One cannot afford to make any mistake in the diagnosis One cannot afford to make any mistake in the diagnosis as it may lead to fatal complications.as it may lead to fatal complications.
When in doubt always err on the right side.When in doubt always err on the right side.
Don’t hesitate to do neuro imaging when you are in Don’t hesitate to do neuro imaging when you are in doubt.doubt.
Summary of Papilloedema
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