Bilateral Optic Disc Swelling for DD
By Dr.Ahmed Ali
What do you think about these photos of a young male 11years old with VA OD CF and OS PL with good projection of light free anterior segment?
By Dr.Mohamed Gamal Elghobaier: Bilateral papilledema ( elevated disc with obscuration of blood vessels and pripapillary hge) which is long standind not acute. What can explain drop of vision is consecutive optic atrophy. Look at the disc of the left side it is paller than that of the right side also vision in the left eye is much dropped.
By Dr.Mona Ahmed: bilateral papillitis may be parainfectous optic neuritis ask about onset ,course and history of recent viral infection , look for vitreous cells
By Dr.Ahmed Hamdi El Motwaly: As papillodema does not affect vision immediately as papillitis which cause rapid drop of vision with pain
By Dr.Shafqat Ali :if history is acute with headach nausea vomitting dipplopia then it is acute pappilledema due to SOL or malignant hypertention [may be due to pheochromocytoma etc] but in this case vision and pupillary reaction should be good along with colur vision and visual acuity as bil swelling of disci with few heamorahges tortous vessels and obscuration of vessels, then he should be immediately advised ct brain to rule out SOL and should be referd to neurosurgeon if no SOL then internist should control bp and look for cause , but poor vision is against, only possible if long standing pappilledema[ but then there should be no heamorahges] and vision and visual feilds should decrease gradualy,if we think of bil optic neuritis as pateint is a child and vision is grossly decreased then sudden decrease vision associated with decrease colour and contrast sensitivity to light there may be history of some viral fever or vaccination or cat sratch etc and associated with slugish puppil or rapd if unequal involvement then we should seek MRI brain , optic nerves and spinal cord to rule out inflamation of optic nerves and to rule out demylination of spinal cord [devic and shilder diseases]should be seen by neurologist. then also should be thourghly investigated for the conditions as mentioned by dr Farooq Khan bove.
Papilledema (or papilloedema) is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks. Unilateral presentation is extremely rare. Papilledema is mostly seen as a symptom resulting from another pathophysiological process.
In intracranial hypertension, papilledema most commonly occurs bilaterally. When papilledema is found on fundoscopy, further evaluation is warranted as vision loss can result if the underlying condition is not treated. Further evaluation with a CT or MRI of the brain and/or spine is usually performed. Unilateral papilledema can suggest a disease in the eye itself, such as an optic nerve glioma.
Papilledema may be asymptomatic or present with headache in the early stages. However it may progress to enlargement of the blind spot, blurring of vision, visual obscurations (inability to see in a particular part of the visual field for a period of time) and ultimately total loss of vision may occur.
The signs of papilledema that are seen using an ophthalmoscope include:
- venous engorgement (usually the first signs)
- loss of venous pulsation
- hemorrhages over and / or adjacent to the optic disc
- blurring of optic margins
- elevation of optic disc
- Paton’s lines = radial retinal lines cascading from the optic disc
On visual field examination, the physician may elicit an enlarged blind spot; the visual acuity may remain relatively intact until papilledema is severe or prolonged.
Optic papillitis is a specific type of optic neuritis. Inflammation of the optic nerve head is called “papillitis” or “intraocular optic neuritis”; inflammation of the orbital portion of the nerve is called “retrobulbar optic neuritis” or “orbital optic neuritis”. It is often associated with substantial losses in visual fields, pain on moving the globe, and sensitivity to light pressure on the globe. It is often an early sign of multiple sclerosis.
Papillitis may have the same appearance as papilledema. However, papillitis may be unilateral, whereas papilledema is almost always bilateral. Papillitis can be differentiated from papilledema by an afferent pupillary defect (Marcus Gunn pupil), by its greater effect in decreasing visual acuity and color vision, and by the presence of a central scotoma. Papilledema that is not yet chronic will not have as dramatic an effect on vision. Because increased intracranial pressure can cause both papilledema and a sixth (abducens) nerve palsy, papilledema can be differentiated from papillitis if esotropia and loss of abduction are also present. However, esotropia may also develop secondarily in an eye that has lost vision from papillitis. Retrobulbar neuritis, an inflamed optic nerve, but with a normal-appearing nerve head, is associated with pain and the other findings of papillitis. Pseudopapilledema is a normal variant of the optic disk, in which the disk appears elevated, with indistinct margins and a normal vascular pattern. Pseudopapilledema sometimes occurs in hyperopic individuals.
Workup of the patient with papillitis includes lumbar puncture and cerebrospinal fluid analysis. B henselae infection can be detected by serology. MRI is the preferred imaging study. An abnormal MRI is associated with a worse visual outcome.
|Definition||Swelling of optic nerve head due to increased ICP||Inflammation or infarction of optic nerve head||Inflammation of orbital portion of optic nerve|
|Vision impairment||Enlarged blind spot||Central/paracentral scotoma to complete blindness||Central/paracentral scotoma to complete blindness|
|Fundus appearance||Hyperemic disk||Hyperemic disk||Normal|
|Vessel appearance||Engorged, tortuous veins||Engorged vessels||Normal|
|Hemorrhages?||Around disk, not periphery||Hemorrhages near or on optic head||Normal|
|Pupillary light reflex||Not affected||Depressed||Depressed|
|Treatment||Normalize ICP||Corticosteroids if cause known||Corticosteroids with caution|