PAPILLOEDEMA

MSHANGILA MD, M.MED

PAPILLOEDEMA
• The terms papilloedema and disc oedema look alike and per se mean
swelling of the optic disc.
• However, arbitrarily the term ‘papilloedema’ has been reserved for
the passive disc swelling associated with increased intracranial
pressure which is almost always bilateral although it may be
asymmetrical.
• The term disc oedema or disc swelling’ includes all causes of active
or passive oedematous swelling of the optic disc.
Causes of disc oedema
1. Congenital anomalous elevation
(Pseudopapilloedema) 5. Vascular causes
2. Inflammations Anaemia
• Papillitis Uremia
• Neuroretinitis Anterior ischaemic optic neuropathy
6. Increased intracranial pressure
3. Ocular diseases See causes of papilloedema
• Uveitis
• Hypotony
• Vein occlusion
4. Orbital causes
• Tumours
• Graves’ orbitopathy
• Orbital cellulitis
Etiopathogenesis of papilloedema
• Causes. Papilloedema occurs secondary to raised intracranial pressure
which may be associated with following conditions:

1. Congenital conditions include aqueductal stenosis and

craniosynostosis.

2. Intracranial space-occupying lesions (ICSOLs).

• These include brain tumours, abscess, tuberculoma, gumma,
subdural haemotoma and aneurysms.
PAPILLOEDEMA
• Papilloedema is most frequently associated with tumours arising in
posterior fossa, which obstruct aqueduct of Sylvius and least with
pituitary tumours.
• Thus, the ICSOLs of cerebellum, midbrain and parieto-occipital
region produce papilloedema more rapidly than the mass lesions of
other areas.
• Further, the fast progressing lesions produce papilloedema more
frequently and acutely than the slow growing lesions.
PAPILLOEDEMA
3. Intracranial infections such as meningitis and encephalitis may be
associated with papilloedema.
4. Intracranial haemorrhages. Cerebral as well as subarachnoid
haemorrhage can give rise to papilloedema which is frequent and
considerable in extent.
5. Obstruction of CSF absorption via arachnoid villi which have been
damaged previously.
6. Tumours of spinal cord occasionally give rise to papilloedema.
PAPILLOEDEMA
7. Idiopathic intracranial hypertension (IIH) also known as pseudotumour
cerebri, is an important cause of raised intracranial pressure.
• It is a poorly understood condition, usually found in young obese women. It
is characterised by chronic headache and bilateral papilloedema without
any ICSOLs or enlargement of the ventricles due to hydrocephalus.
8. Systemic conditions include malignant hypertension, pregnancy induced
hypertension (PIH) cardiopulmonary insufficiency, blood dyscrasias and
nephritis.
9. Diffuse cerebral oedema from blunt head trauma may causes papilloedema
Unilateral versus bilateral papilloedema.
• Disc swelling due to ocular and orbital lesions is usually unilateral.
• In majority of the cases with raised intracranial pressure,
papilloedema is bilateral.
• However, unilateral cases as well as of unequal change do occur with
raised intracranial pressure
PAPILLOEDEMA
• Clinical features
[A] General features.
Patients usually present to general physicians with general features of
raised intracranial pressure.
These include headache, nausea, projectile vomiting and diplopia. Focal
neurological deficit may be associated.
[B] Ocular features. Patients may give history of recurrent attacks of
transient blackout of vision (amaurosis fugax).
• Visual acuity and pupillary reactions usually remain fairly normal until the
late stages of diseases when optic atrophy sets in.
 PAPILLOEDEMA
• Clinical features of
papilloedema can be
described under four stages:

1. Early 2. Fully developed.

Normal
3. Chronic. 4. Atrophic
Differential diagnosis
• Papilloedema should be differentiated from pseudopapilloedema and
papillitis.
• Pseudopapilloedema is a non-specific term used to describe elevation
of the disc similar to papilloedema, in conditions such as optic disc
drusen, hypermetropia, and persistent hyaloid tissue.
The differentiating points between papilloedema,
papillitis and pseudopapilloedema
Feature Papilloedema Papillitis Pseudopapillitis
1. Laterality Usually bilateral Usually unilateral or May be unilateral
bilateral
2. Symptoms Transient attacks of Marked loss of vision of Defective vision
(i) Visual acuity blurred vision sudden onset
Later vision decreases due
to optic atrophy
(ii) Pain and tenderness Absent May be present with Absent
ocular movements
3. Fundus examination
(i) Media Clear Posterior vitreous haze Clear
is common
(ii) Disc colour Red and juicy appearance Marked hyperaemia Reddish
Disc margins Blurred Blurred Not well defined
Disc swelling 2-6 dioptres Usually not Depending upon the
more than 3 dioptres degree of hypermetropia
The differentiating points between papilloedema,
papillitis and pseudopapilloedema(cont)
Feature Papilloedema Papillitis Pseudopapillitis
(iii) Peripapillary oedema Present Present Absent
(iv) Venous engorgement More marked Less marked Not present
(v) Retinal haemorrhages Marked Usually not present Not present
(vi) Retinal exudates More marked Less marked Absent
(vii) Macula Macular star may be Macular fan may be Absent
present present
4. Fields Enlarged blind spot Central scotoma No defect
more for colours
PAPILLOEDEMA
• Treatment and prognosis
• It is a neurological emergency and requires immediate hospitalisation.
• As a rule unless the causative disease is treatable or cerebral
decompression is done, the course of papilloedema is chronic and
ultimate visual prognosis is bad.