Papilledema and Optic nerve swelling

Papilledema is a condition where increased pressure in or around the brain causes optic nerve swelling inside the eye.

Patients may present with multiple symptoms when they have this condition.  They can present with headaches, ringing in ears, flickering in the vision, double vision, vision loss (sometimes unilateral and sometimes bilateral), nausea, vomiting, visual field defects and sometimes a decrease in the vision or blurred vision.

When a doctor looks in the back of the eye at the optic nerves, the will see bilateral swollen optic nerves.  One optic nerve may be more swollen than the other and the disc margins may be blurred as well. There may be hemorrhages around the optic nerve, cotton wool spots, and dilated veins in and around the nerve as well.  Also, there is no pupillary defect because both eyes are involved and color vision is normal.

When there is papilledema in the patients eye, certain conditions must be ruled out to determine the cause of the problem.  Optic nerve drusen can sometimes look like papilledema and it is not true disc swelling. The difference is that with drusen, the vessels on the edge of the disc will not appear fuzzy, they will be well defined and also the disc will not appear a brighter red color.  Another differential is papillitis.  With this condition, there is a pupillary defect (APD) and most of the time color vision is affected. Hypertensive optic neuropathy must also be ruled out.  This usually presents with hemorrhages with or without cotton wool spots extending into the peripheral retina.  There are usually more defects in the retina as well and not just the optic nerve. Another differential is Central Retinal vein occlusion. The hemorrhages usually extend far beyond the peripapillary area, there are dilated and tortuous veins and there is usually acute vision loss.

Papilledema causes include:

– intracranial tumors

– idiopathic intracranial hypertension (Pseudo tumor cerebri), seen in over weight women predominantly

– hematomas (blood clots) in brain

– Brain Abscess

– Meningitis

What should be done with these patients?  Work up should include:

– Emergency MRI with and without contrast and MRV of the head.

– Lumbar puncture and cerebral spinal fluid analysis

The treatment should be directed at the underlying cause of the increased intracranial pressure.

Case study:   35 year old female complains of a headache that has been going on for a month along with her vision “blacking out” on her at least twice daily.  She was over weight as well.

After thorough examination, it was found that the only ocular finding was that both of her optic nerves were swollen.   She was sent for a STAT MRI/MRV and it was found that she had idiopathic intracranial hypertension also known as Pseudo tumor cerebri).  She was given diamox to help bring down the pressure and also was educated to lose weight.  These both will help with the condition.  She will be followed closely.

Do you experience headaches or loss of vision?  Give us a call at Metrolina Eye Associates, to schedule an appointment.