Transcript
Optic nerve swellinghow to deal with ?!
You can notice: Disc hyperemia Blurred margins Nerve fiber layer (NFL) opacification and
swelling Disc elevation Tortous veins
A male pt 15 years old , came to outpatient clinic complaining of persistent headache for the last 2 months .
The headache was mainly at waking, increased by coughing, associated with nausea and vomiting
history
Visual acuity, color vision, and pupillary examination were normal.
examination
Dilated fundus examination showed :
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
Papilledema Vs pseudopapilledema
Tilted disc
optic head drusen
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
PRESENTATION : mild diminution of vision, progressive monocular visual loss.
OCULAR FINDINGS: modest decrease in VA (6/12 or better), disc swelling may be unilateral or bilateral, visual field defects (general constriction or scotoma), ± RAPD and dyschromatopsia.
Others : + systemic vasculopathy
1-Diabetic papillopathy
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
PRESENTATION : painless reduction in VA This is monocular but the fellow eye can be affected in unfortunate patients.
OCULAR FINDINGS: mild-to-severe, sudden or progressive (over weeks) reduction in VA (if severe, RAPD may also be present), dilated, tortuous veins, diffuse retinal haemorrhages and disc oedema. Later on, there may be conjunctival congestion and disc oedema.
OTHERS: evidence of systemic ds (Cardiac, clotting ds,..)
2-CRVO
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
PRESENTATION: decreased VA and episodes of temporary visual loss. May be asymptomatic.
OCULAR FINDINGS: attenuation of arterioles (copper wiring), arteriovenous nipping (narrowing of the veins as the arteries pass over them) and signs of vascular leakage (haemorrhages and exudates). Disc swelling occurs in the presence of very high blood pressure
OTHERS : systemic HTN , ‘most common cause of disc swelling’
3-Malignant hypertension
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
(Non arteretic)
NATURE: this is a partial or total infarction of the optic nerve head due to occlusion of the posterior ciliary arteries. Patients tend to be in the 45-65 year-old age group and predisposing factors include hypertension, diabetes, hypercholestrlemia
PRESENTATION: sudden painless monocular visual loss (often discovered on waking)
4-AION
NATURE: Granulomatous inflammation of vessels involving the elastic tissue, There is a predilection for the temporal, ophthalmic, posterior ciliary and vertebral arteries.
PRESENTATION: one or more of jaw claudication, scalp tenderness, neck pain, malaise, temporal artery tenderness, visual reduction or loss in the patient over 55 years of age (some argue that this condition does not occur before the age of 60 or 65 years). Episodes of amaurosis fugax may occur prior to infarction of the optic nerve head. Patients may also complain of flashing lights and periocular pain.
• (Arteretic ; giant cell arteritis)
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
Inflammation of the optic nerve, which can occur as a result of demyelinating or infective disease processes. The optic nerve head is occasionally swollen but pallor of the disc is the norm.
5-Optic neuritis
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
PRESENTATION: reduced vision; may complain of diplopia if globe movement is restricted. Large lesions may also cause epiphora (tearing) and discomfort as a result of proptosis and the patient may complain of a red eye due to congested blood vessels.
OCULAR FINDINGS: few or no findings to a proptosed eye which is congested (conjunctiva is red and may be oedematous) and has a limited range of movement. VA reduced in later stages and there may be an RAPD
6-space occupying lesion of the optic nerve head
papilledema (d.t increased ICP). space occupying lesion of the optic nerve
head optic neuritis AION malignant hypertension CRVO Diabetic papillopathy others (panuveitis, scleritis, thyroid eye dis,
meningitis, uremia,…..)
Differential diagnosis of optic disc swelling ..
swelling of the optic disc from increased intracranial pressure (ICP)]
7- papilledema
Causes
1- space occupying lesion 2- decreased CSF drainage3-Idiopathic Intracranial Hypertenion4-increased CSF production such as from a choroid plexus tumor
DETECT ?!
Headache Nausea and vomiting . Visual fields often demonstrate increased size
of the blind spot. transient visual obscurations. Farsightedness (hypermetropia) may increase pulsatile tinnitus. peripheral visual field loss as seen in IIH. cranial nerve palsies, usually an abducens
palsy
Symptoms :
According to grading:
signs
Grade I papilledema is characterized by a C-shaped halo with a temporal gap
Grade II papilledema, the halo becomes circumferential
Grade III papilledema is characterized by loss of major vessels AS THEY LEAVE the disc (arrow)
Grade IV papilledema is characterized by loss of major vessels ON THE DISC.
Grade V papilledema has the criteria of grade IV plus partial or total obscuration of all vessels of the disc.
Fluorescein angiography
Perimetry: enlarged blind spot
CNS imaging study (CT or MRI with contrast).
The primary cause of the increased intracranial pressure must be addressed. If a mass is present, primary therapy should be directed towards that. If medications (tetracyclines, vitamin A analogues, etc.) are felt to be causative they should be discontinued.
The visual prognosis is generally good if the intracranial pressure is controlled.
Prognosis
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