Papilledema
Overview
Swelling of the head of the optic nerve (optic disk) due to increased intracranial pressure.
Symptoms
* Headache * Nausea * Vomiting * Vision symptoms * Transient loss of vision * Reduced field of vision
Causes
* Pseudotumor cerebri (idiopathic intracranial hypertension) –Most common cause of papilledema –Young, obese, or pregnant females –Associated with vitamin A overdose, OCPs, tetracycline, steroid withdrawal * Cerebral tumor (primary or metastatic) * Hydrocephalus (e.g., tumor, Arnold-Chiari malformation, aqueductal stenosis, postinfectious) * Intracranial hemorrhage (papilledema may not be seen acutely because it takes about 24 hours to develop after the ICP increases) –Subdural hematoma –Subarachnoid hemorrhage –Hemorrhagic stroke –Epidural hematoma * Intracranial infection –Brain abscess –Encephalitis (e.g., herpes) –Neurosyphilis –Toxoplasmosis * Meningitis (e.g., bacterial, viral, TB) * Malignant hypertension * Pre-eclampsia Optic disc swelling not due to increased ICP * Pseudopapilledema (the vessels traversing the disk margins are obscured, as in true papilledema): Optic disc drusen or congenitally anomalous disc * Papillitis: Unilateral, painful, vitreous cells * Papillophlebitis: Mild visual loss and disk swelling in young, healthy patient * Central retinal vein occlusion: Unilateral, associated with an acute loss of vision * Diabetic papillopathy: Disk edema with minimal visual loss, resolves spontaneously * Optic-disc vasculitis/ischemic optic neuropathy (giant cell/temporal arteritis) * Orbital optic-nerve tumors * Graves’ ophthalmopathy: History of thyroid dysfunction; may be associated with lid lag, proptosis, increased intraocular pressure * Uveitis: Associated with pain, photophobia, and scleral injection * Atypical optic neuritis
Diagnosis
Regardless of whether there are focal neurologic signs or hypertension, a CT scan or MRI should be done, and a consultation with a neurologist should be made when papilledema is suspected. If there is significant hypertension and the CT scan or MRI are negative, a hypertensive workup should be done . With a normal CT scan or MRI and no focal neurologic signs or hypertension, a spinal tap and visual field examination will assist in the diagnosis of pseudotumor cerebri. However, a blood lead level should be done to rule out lead poisoning. Also, the visual field exam may show optic neuritis when the clinical examination was inconclusive. An ophthalmologist will help diagnose optic neuritis and pseudopapilledema.
Treatment
* Pseudotumor cerebri may be self-limited with weight loss, discontinuation of offending medications; diuretics may be used (e.g., acetazolamide) to decrease CSF production, lumboperitoneal shunting or optic nerve sheath decompression may be indicated in some cases * Intracranial tumors may require resection * Hydrocephalus: Surgical correction of anatomic abnormalities, with or without VP shunt * Intracranial hemorrhage: Conservative management versus surgical evacuation depends on size and location –Acute subdural hematoma: Control elevated ICP with osmotic and loop diuretics and mild hyperventilation; emergent craniotomy for evacuation of hematomas that result in significant mass effect –Epidural hematoma: Usually does not require surgery; hyperventilation and mannitol to decrease ICP * Intracerebral infections require appropriate antibiotics * Encephalitis: Control ICP by hyperventilation, diuresis * Malignant hypertension: Aggressive IV pressure control