Download The Swollen Optic Disk

Sleuthing
The Swollen Optic
Disk
A non-specific Finding…..
…..Warrants a Thorough
Evaluation
Speaker Disclaimers
• Corporate Compensation: None
• Investments/Interests: None
Critical First Test:
•Unilateral or Bilateral?
– Unilateral  “optic neuropathy”
– Bilateral  “papilledema”
• Until proven otherwise
Malignant Hypertension
“Post-op Vision Loss, OU”
Critical 2nd Test:
• TRUE Edema vs PSEUDOedema
Critical 3rd Test:
•Check Blood Pressure
– Malignant Hypertension?
• With or Without HTN retinopathy!
Critical 4th Test:
• REVIEW of SYSTEMS
–Health Hx.
–Medications Hx.
–Symptoms
Polycythemia
Is there PAIN???
• Ocular?
• Head?
B.P. spike with N.A.I.O.N.
“HURTS behind my eye”
What Do The Visual Fields Look
Like?
• OD, OS, or OU?
• RNFL “bundle defect”
• Central or Ceco-central
defect
• Enlarged Blindspot
and overall depression
Causes of TRUE
Disk Edema
#1 ISCHEMIA
1st Anterior Ischemic Optic Neuropathy
2nd C.R.V.O. (venous stasis)
3rd Malignant Systemic Hypertension
4th Carotid-Cavernous Sinus Fistula (rare)
5th Diabetic Papillopathy (rare)
“Healthy 23 y.o. male”
#2: BLOCKAGE of RETROGRADE FLUID FLOW
1st
Axonal and Intraneuronal C.S.F.
- Raised intracranial pressure
+ Bilateral
+ “Papilledema”
2nd
Venous Blood
- C.R.V.O.
3rd
Axonal and Intraneuronal C.S.F.
- Optic Nerve Tumor
- Orbital Mass Effect
#2: BLOCKAGE of RETROGRADE FLUID
FLOW
4th Bilateral Venous Outflow
- C.C.S.F.
- cerebral venous sinus thrombosis
- right heart failure
- pulmonary hypertension
- sleep apnea
- superior vena cava syndrome
- jugular vein occlusion
- dural fistula
#3: INFLAMMATION
1st Papillitis
st
1 Anterior Optic Neuritis
#4: OPTIC DISK TRAUMA
• Optic Nerve Contusion
#5: TOXICITY and
NUTRITIONAL NEUROPATHY
•
•
•
•
“Moonshine Retinopathy”
Drug Addiction
Annorrhexia
Bulimia
#6: DRAMATIC I.O.P. CHANGE
• Acute Glaucoma
• Ocular Hypotony
Causes of
Non-Edematous
(“without fluid”)
Disk Elevation & Thickening
#1: OPTIC DISK IRREGULARITIES
#1)
#2)
#3)
#4)
Disk Drusen
Crowded Disk
Tilted Disk
Myelinated
Nerve Fibers
#2: LEBER’S HEREDITARY OPTIC NEUROPATHY
• Suspect in any case of BILATERAL
“idiopathic” optic neuropathy
• Inherited mitochondrial disease
• Passed on by Mom
• Affects both genders
• Affects all ages
• Diagnosis: Genetic Testing
#3: OPTIC DISK INFILTRATION
#1) Metastasis
- breast
- lung
#2) Primary Tumor
#3) Leukemia
#4) Lymphoma
#5) Sarcoidosis
Key Findings
TRUE
DISK EDEMA
Look For:
• Elevation
• Peripapillary Retinal Sheen
• Circumferential Retinal
Folds
• Radiating Retinal Folds
• Whitening of the
peripapillary
retinal nerve fiber layer
Retinal Folds?
•
•
•
•
Blurry Disk Margins
SmallLarge Vessel Obscuration
Venous Bloating & Tortuosity
Peripapillary/Papillary
Hemorrhages
• Juxtapapillary Exudates
• Fluid Pockets/ “Bags” on OCT
• Leakage (not “late staining”)
on Fluorescein Angiography
TRUE Disk Edema…..
Now What????
Is it Papilledema
Or
Is it Optic Neuropathy
???????
LATERALITY
• Unilateral
vs
• Bilateral
vs
• Bilateral, Asymmetric
VISUAL ACUITY
•Reduced “early on…”
vs
•Not reduced until late
COLOR VISION
•Reduced “early on….”
vs
•Not reduced until late
CONTRAST SENSITIVITY
•Grossly Reduced
vs
•NOT Reduced
VISUAL FIELDS
• OPTIC NEUROPATHY
– Central depression
– Macular bundle depression
– Arcuate pattern depression
– Altitudinal pattern depression
• PAPILLEDEMA
– Enlarged blindspots
– Scattered nasal field defects
– Overall peripheral depression
T.V.O. ASSESSMENT
• Transient Visual Obscurations
– One eye?
– Both eyes?
• “How do changes in posture
affect your vision?”
• “What if you bend over?”
RAISED INTRACRANIAL
PRESSURE
SYNDROME
1) Look carefully at BOTH disks!!!
• Papilledema almost always present
• Spontaneous Venous Pulsation almost always
absent
2) Look carefully at SYMPTOMS!
•
•
•
•
•
•
•
Headache
Transient Visual Fluctuations
Pulsatile Tinnitus
Nausea
Vomiting
Horizontal Diplopia—worse at Far
Focal neurologic symptoms
elsewhere in the body
Compare that to:
EDEMATOUS OPTIC NEUROPATHY
• Symptoms primarily ocular/visual
• Usually Hx of underlying disease
• May be “classic symptoms” of that associated
disease
– Cranial arteritis
– Lyme disease
– Cat scratch disease
You now DO suspect
Papilledema….what next?
Preferred Practice Patterns advise:
IMAGING
IS MANDATORY!
CT of Head (advisable)
• DETECTS:
–Large masses
–Intracranial hemorrhaging (fresh
blood)
–Hydrocephalus
Uh, Oh.
CT is “WNL”
…….But I still think my patient has
papilledema…….Now What?
MRI of BRAIN with contrast
• DETECTS:
•
•
•
•
Intracranial masses
Infiltrates
Cerebral venous thrombosis (+/-)
Meningeal pathologies
CT and MRI are Normal
but Papilledema still suspected?
• LUMBAR PUNCTURE
– With CSF opening pressure
• Normal < 200mm
• Questionable 201-250mm
• Elevated > 250mm
– With CSF laboratory analysis
• Normal = idiopathic intracranial hypertension likely
• Abnormal: chronic meningitis, spinal cord tumor, etc.
Diagnosis still in Doubt?
• R/O VENOUS SINUS THROMBOSIS
– MRV of HEAD and NECK
Diagnosis still in Doubt?
• Etiology must be a systemic venous return
issue……
– Extensive cardiovascular workup indicated
– “Emphasis on venous return pathologies”