Papilledema

Background

• Bilateral optic disc swelling due to increased ICP
• This may sometimes be a presenting complaint, referred by an eye care provider, though will usually have associated symptoms such as headache, altered mental status, or vision changes.

Etiology

• All causes of elevated intracranial pressure
  • Intracranial mass
  • Decreased CSF outflow or resorption
  • Increased CSF production or cerebral blood flow
• Most commonly caused by Idiopathic intracranial hypertension in individuals under 50.

Clinical Features

• Increased ICP symptoms:
  • Headache (esp with recumbency and in the morning)
  • Nausea and vomiting
• Visual disturbance
  • Visual acuity is usually normal or near-normal in the acute phase
  • May have transient visual obscurations (blurriness or white out) that last seconds, then clear completely.
    • These may be triggered by position change or Valsalva

Fundoscopy

• Loss of spontaneous venous pulsations
• Disc margin blurring
• Cup is diminished or absent

Differential Diagnosis

• Idiopathic intracranial hypertension (other causes must be excluded)
• Intracranial mass
• Hydrocephalus
• Cerebral venous thrombosis
• Cerebral edema
  • Ischemic stroke
  • Traumatic brain injury
  • Salicylate toxicity
  • Meningitis
  • Encephalitis
  • Posterior reversible encephalopathy syndrome

Evaluation

• Careful neurologic exam including level of consciousness, pupils, and cranial nerves (especially CN VI-Abducens)
• Fundoscopic exam without dilation is often difficult - consider ocular ultrasound to assess optic nerve diameter
• Brain MRI with MR venography to identify secondary causes of elevated ICP
  • Non-contrast head CT with CT venography may be a reasonable alternative depending on practice setting and patient urgency. Follow-up MRI may be required.
• Lumbar Puncture (if neuroimaging normal)
  • Opening pressure >25 considered abnormal

Management

• Treat underlying condition

See Also

• Increased ICP