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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 SmallLarge 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”