optic nerve head swelling

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





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





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





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





(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)





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





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





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

optic nerve head swelling

Health & Medicine

thyroid eye

space occupying lesion

papilledema d

visual reduction

disc oedema

visual acuity

fellow eye

common cause of disc