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