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Papilledema and Raised Intracranial Pressure
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Of the various abnormalities of the optic disc, papilledema or optic disc swelling has the greatest neurologic implication, for it signi es the presence of increased intracranial pressure It must be made clear, however, that an ophthalmoscopic appearance identical to that of papilledema can be produced by infarction of the optic nerve
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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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Figure 13-8 Mild papilledema with hyperemia of the disc and slight blurring of the disc margins
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Figure 13-10 Chronic papilledema with beginning optic atrophy, in which the disc stands out like a champagne cork The hemorrhages and exudates have been absorbed, leaving a glistening residue around the disc
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head (anterior ischemic optic neuropathy) and by in ammatory changes in the intraorbital portion of the optic nerve ( papillitis or optic neuritis) Certain clinical and funduscopic ndings, listed in Table 13-1 and described below, assist in distinguishing these processes, although all share the basic feature of conspicuous disc swelling In its mildest form, papilledema may take the form of only slight elevation of the disc and blurring of the disc margins, especially of the superior and inferior aspects, and a mild fullness of
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Figure 13-9 Fully developed papilledema The main characteristics are marked swelling and enlargement of the disc, vascular engorgement, obscuration of small vessels at the disc margin as a result of nerve ber edema, and white cotton-wool spots that represent super cial infarcts of the nerve ber layer
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the veins in the disc Subtle disc elevation is also indicated by a loss of de nition of the vessels overlying the disc as they approach the disc margin from the periphery; this appearance is produced by edema in the adjacent retina Since many normal individuals, especially those with hypermetropia, have ill-de ned disc margins, this early stage of papilledema may be dif cult to detect (Fig 13-8) Pulsations of the retinal veins, best seen where the veins turn to enter the disc, will have disappeared by the time intracranial pressure is raised, but this criterion is not absolute, since venous pulsations are not present in 10 to 15 percent of normal individuals On the other hand, the presence of spontaneous venous pulsations is a reliable indicator of an intracranial pressure below 180 to 190 mmH2O and thus usually excludes the presence of early papilledema (Levin) Fluorescein angiography, red-free fundus photos (which highlight the retinal nerve bers), and stereoscopic fundus photography may be helpful in detecting early edema of the optic discs More severe degrees of papilledema appear as further elevation, or a mushrooming of the entire disc and surrounding retina, with edema and obscuration of vessels at the disc margins and, in some instances, peripapillary hemorrhages (Fig 13-9) When advanced, papilledema is almost always bilateral, although it may be more pronounced on the side of an intracranial tumor A purely unilateral edema of the optic disc is usually associated with perioptic meningioma or other tumor involving the optic nerve, but it can also occur at an early stage of increased intracranial pressure As the papilledema becomes chronic, elevation of the disc margin becomes less prominent and pallor of the optic nerve head, representing a dropout of nerve bers (atrophy), becomes more evident (Fig 13-10) Varying degrees of secondary optic atrophy are left in the wake of papilledema that has persisted for more than several days or weeks, leaving the disc pale and shrunken A constriction in one quadrant of the nasal eld is an early sign of the loss of nerve bers Unlike the case in primary optic atrophy, the disc margins are irregular, often with peripapillary pigment deposits A point to be emphasized is that acute papilledema, while it may enlarge the blind spot slightly, does not greatly affect visual acuity (except transiently during spontaneous waves of increased intracranial pressure) Therefore optic disc swelling in a patient
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