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Grading and differential diagnosis of Papilledema

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dr. zehralyarazali

on 4 April 2015

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Transcript of Grading and differential diagnosis of Papilledema

non inflammatory swelling of optic nerve head
due to increased intracranial tension (ICT)
always bilateral
edema occurs due to block axoplasmic flow
Grading and differential diagnosis of Papilledema
Clinical Picture
Early stage :
- asymptomatic
-primarily, having a symptom of increase of ICT
eg: headache, nausea and projectile vomitting

Progressive stage :
-amaurosis (blackout phenomenon)
-vision of flickering

Late stage ( if not treated) :
-atrophic papilledema (secondary optic atrophy)
-painless diminution of vision
-blindness if not treated

2 ways :
First , by Frisen Scale which differentiate into grade 0,1,2,3,4,5
Second, according to severity and chronicity
Prepared by :
Fatiah Aisyah bt Izani
Nurizati Hamizah bt Abd Rahim
Nurzahirah Aalia bt Mohd Razali
Siti Nur Sabiha bt Ahmad Fadzil
Wan Farah Nasuha bt Wan Muhammad Husni
neoplasms. the most common cause
inflammatory, eg: meningitis
vascular, eg: haemorrhage
pseudotumor cerebri. idiopathic intracranial hypertension
Ophthalmoscopic examination

Pupil examination
-Early stage : direct and consensual pupillary reflexes are completely normal
-Late stage : RAPD
Field vision testing
-Enlarged blind spot.
-Contracted field vision due to optic atrophy
Normal optic disc
Minimal swelling of nasal margin.
No vessels obscuration.
Radial nerve fiber layer (NFL) clear.
Cup if present is not obscured.

Hallmark: No C-shaped halo with temporal gap.
Very early papilledema.
230 degree swelling of nasal, superior and inferior border.
Temporal margin is normal .
Cup if present is maintained.

Hallmark: C-shaped halo with temporal gap.
Early papilledema
360 degree disc swelling.
Elevation temporal margin.
No major vessels obscuration.

Hallmark: The halo become circumferential.
Moderate papilledema.
Elevation entire disc.
360 degree swelling.
Partial vessels obscuration at disc margin.
Cups maybe obscured.

Hallmark: Loss of major vessels as they leave disc.
Marked papilledema.
NFL opaque / 360 degree swelling.
Vessels largely but not completely obscured on disc surface and lost at the margin.

Hallmark: Loss of major vessels on the disc.
Severe papilledema.
NFL opaque / 360 degree swelling.
Vessels obscured on disc surface.

Hallmark: Partial or total obscuration of all vessels on the disc.
Grading according to
Frisen Scale
Grading according to severity and chronicity
Early Papilledema :
Disc elevation
Venous distension and tortuousity
Obscuration of normal disc margin
Established Papilledema :
Marked elevation of nerve head
Engorged tortuous venules
Peripapillary splinter haemorrhages
Hard exudates
Chronic Papilledema :
Disc hyperemia decrease.
Disc progressively pale
Optociliary shunts
Field of vision
Color of vision
Neurological investigation
Visual evoked potential (VEP)
Blood test

enlargement of the blind spot.
total blindness.
Color vision

central scotoma for blue
differentiate from papillitis which caused green and red scotoma
Neurological ivestigation

Urgent neuroimaging (eg, CT scan, MRI)
to identify a CNS mass lesion
to detect venous sinus thrombosis.
B-scan ultrasonography
to rule out buried disc drusen

Differential Diagnosis
Idiopathic Intracranial Hypertension
Optic Neuritis, Adult
Optic Neuropathy, Anterior Ischemic
Optic Neuropathy, Compressive
Thyroid Ophthalmopathy
Toxic/Nutritional Optic Neuropathy
Vogt-Koyanagi-Harada Disease

Disc drusen
- small conglomerates of mucopolysaccharides
and proteinaceous material - calcified with advancing age.
- mistaken as papilledema and hence it is called as pseudopapilledema.

eye disorder -inflammation of the optic disc papilla.

- demyelinating disease (MS)
- Metabolic disease as diabetes mellitus
- Infection from other disease as tuberculosis and poliomyelitis.
-Extension from other infections

Clinical picture

- rapid and marked reduced visual acuity in
one eye

- blurring of the disc margins
- filling in the cup, edema
-exudates and hemorrhages
- vitreous is turbid
- central scotoma for red and green
-usually unilateral.

• Recovery in most cases after few weeks.
• Postpapillitic optic atrophy with recurrence is common



Clinical picture

Symptoms -asymptomatic

- no obscuration of the peripapillary vessels
-unilateral or bilateral,
- disc is yellow, the cup may be small or absent
-venous congestion is not present
- spontaneous venous pulsations often present

Visual field loss
-gradual field constriction.

- progressive visual field loss
- rarely loss of central acuity
- very rare cases, blindness.

treat the cause
commonly is prescribed with diuretics
complicated by optic nerve atrophy lead to diminution of vision- post papilledemic atrophy.
optic disc become grayish, flat with obscured lamina cribrosa.

Fate of Papilledema
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