Download The Not-So-Skinny on Papilledema

July 2015
OWL Award for Woman Leadership
The Not-So-Skinny on Papilledema
During the recent ASCRS meeting,
Northwest Eye Surgeons’ own Audrey
Talley Rostov was recognized with the
Visionary Woman Award. The award,
presented by the Ophthalmic Women
Leaders (OWL) organization, honors
an ophthalmic professional who has
paved the way for other women in the
field through her achievements.
By Landon Jones, OD
The achievements, qualifying Dr.
Rostov for the award, include her
service on the medical advisory board
of Sightlife, her surgical instruction of
femtosecond laser keratoplasty
technique to surgical staff in New
Delhi, India, and her work with the
Himalayan Cataract Project, to create
a cornea fellowship for Ethiopian
surgeons.
More information about the DSEK
technique that Dr. Rostov taught to
other surgeons can be found on our
website: www.nweyes.com.
While acquired optic nerve edema occurs infrequently, the cases that do
present can be challenging. Misdiagnoses or suspicion of papilledema are
often referred in by general
practitioners or emergency
room physicians. These
patients rightfully present
with anxieties attached to
the diagnosis. This article
acts as a terse overview for
the condition of papilledema
and its differentials.
Papilledema Defined
Disc edema is a general,
non-specific term referring
to a multitude of potential
disease etiologies. In
Left optic nerve of a 13 year old boy who presented with
addition to papilledema,
papilledema. Photo courtesy of Merge.com
disc edema includes
conditions such as optic neuritis, optic neuropathy, and diabetic papillopathy,
among others.
Optic nerve papilledema refers specifically to swelling of the optic nerve as a
result of elevated intracranial pressure. This term can be considered as a
clinical finding. Pseudotumor cerebri, a synonym to Idiopathic Intracranial
Hypertension, is the true diagnosis or cause of the papilledema when spaceoccupying lesions have been ruled-out. It is deemed a diagnosis of exclusion.
The most common space-occupying lesions which can rule-out papilledema
include intracranial tumors, subarachnoid hemorrhage, and subdermal
hematomas.
It is important to rule out benign causes of optic disc elevation when examining
patients that are suspect for papilledema. Optic disc drusen and anatomically
crowded optic nerves are both forms of pseudopapilledema that can fool the
practitioner into believing that the nerve is edematous. B-scan and OCT of the
peripapillary area can both be utilized to help make this diagnosis more
definitively.
Incidence and Demographics
Audrey Talley Rostov, MD, with NWES CEO
Maureen Tipp and Business Operations
Manager, Susan Oliveto, at 2015 ASCRS
meeting in San Diego.
It is widely accepted that a higher incidence of pseudotumor is linked to a
higher incidence of obesity across the globe. The most likely demographic is
obese women during childbearing years. These facts, along with weight gain
contributing to higher recurrence rates, supports obesity as one of the most
likely theorized etiologies. Many studies consider it more of a strong chance
Continued on page 4
“Life Is Good”
Photo courtesy of C. Freeman
A Patient Recounts Cataract
Surgery with Vision Correction
I was living with creeping glaucoma
and cataracts, unaware of how bad it
was getting, when my local eye guy
said something needed to be done,
and recommended Northwest Eye
Surgeons.
They fixed my right eye in December,
and a month later, my left. After the
right eye [surgery], white was white,
red was red, and edges were sharp.
When I closed my right eye and looked
out of my unfixed left eye, it was a
blurred view through a nicotine
stained window, which proved to me
that you won’t know how bad it was
until someone makes it better.
I can’t praise NWES enough. They
were kind, humorous, polite and
timely. Better yet, they told me what to
expect, what they were going to do
and then did it. They were what I
always expect and seldom get.
Now, when I look at a mountain top, I
see a mountain top. Life is good.
-NWES patient Charlie Freeman
Education Highlights: Tried and Tested Along With a
New Offering!
On April 29th, we were pleased to
present the 5th annual MultiDisciplinary Spring Symposium at
the Lynnwood Convention Center.
This year’s four-hour CE covered
the broad topic of
Oncology. Northwest Eye Surgeons
staff presenters included Dr.
Michael Giese, providing an update
on ocular side effects of cancer
treatments, Dr. Tom Osgood,
discussing external lesions and
Drs. Paul Griggs and Richard Lee covering retinal oncology. Guest expert Nancy
Thompson, RN, AOCNS, rounded out the program with prevention updates and
a high-level outline of the issues impacting patients who are undergoing or
recovering from cancer treatment, or receiving palliative care. Guest speaker
and neurosurgeon, Johnny Delashaw, MD, closed the program, providing an
anatomy review and detailing surgical interventions for removing lesions of the
visual pathway. Mingled with our education was a delicious dinner and time for
the 245 ODs in attendance to mingle and share personal and professional
updates with each other. We are committed to continuing this popular program.
We offered our First Annual Resident Grand
Rounds at the Shoreline Conference Center on
Wednesday, May 27th. Attendees enjoyed a
catered dinner while five Washington-located
optometric residents presented cases from their
training, covering topics including Papilledema
and Central Serous Retinopathy. We are excited
to make this an annual event and to see more of you there next year. Keep up
to date on future education offerings on our website: www.nweyes.com.
Practice Update
Femtosecond Laser Adds to Vision Correction Armamentarium
By Tom Osgood, MD
In addition to making precise incisions for the paracentesis, corneal tunnel, capsulorhexis and
phacofragmentation, the femtosecond laser also makes perfect limbal relaxing incisions (LRIs). The
precision that femtosecond laser technology adds to our ability to treat astigmatism is demonstrated in
the following case.
Case: Mr. W. is a skeptical seventy-nine year old retired Boeing engineer. His pre-op MR and K’s are
shown below.
Manifest Refraction:
K’s
OD: -0.50 + 1.00 x 174
OD: 44.66/45.52 x 170
OS: -1.25 + 1.25 x 113
OS: 43.75/46.03 x 102
I was not able to convince Mr. W. that without treating his astigmatism he would end up with more
astigmatism than he had preoperatively, because removing the lens would allow the full corneal
astigmatism to manifest. Fortunately, I was able to offer LRI.
Mr. W. desired to have good uncorrected near vision at 20 to 22 inches. Therefore, I targeted -1.75 D.
During his left cataract surgery the femtosecond laser was programmed to make paired 42 degree arcs, at
a radius of 9.2 mm, centered on the steep corneal axis of 102-282 degrees. The laser cut beautiful,
perfect arcs at 80 percent of corneal depth. Postoperatively, in the left eye, Mr. W. could see J1 without
correction and 20/40 at a distance, without correction, but he wanted even better near vision for his right
eye. I then targeted his right eye for -2.25 D and performed a similar surgery with femtosecond laser LRIs.
Mr. W. is now extremely happy with his uncorrected near vision. Even his uncorrected distance vision is
good enough at 20/40 that he does not wear glasses. His post-op MR and acuities are:
SC OD: 20/100 (-2.50 sph) 20/20 J1+
SC OS: 20/40 (-1.50 + 0.25 x 90) 20/25 J1
This case points to the precision of the femtosecond laser in making perfect LRI incisions, rivaling that of
LASIK. With Vision Correction, one advantage of femtosecond laser LRIs is that they can be used in
combination with Toric IOLs to treat high degrees of astigmatism. Femtosecond laser LRI’s can even be
titrated for more effect, either during surgery in conjunction with ORA (intraoperative aberrometry), or later
in the post-op period, by gently “opening” the LRI to give more effect. In Mr. W’s case this was not needed,
but is an option that can be added to our Vision Correction armamentarium.
Femtosecond Laser with Vision Correction is available now in our Mount Vernon and Seattle clinics.
Our physicians would be glad to talk with you further about incorporating femtosecond laser into your
patient’s cataract surgery planning. For more information reach us at 800-826-4631.
10330 Meridian Ave. N.
Suite 370
Seattle, WA 98133
Medical Article: Papilledema, continued from page 1
CONTINUING EDUCATION
SEPTEMBER 17 | THURSDAY
OCT Analysis of Nerve and Macula
Drs. Meng Lu and Richard Lee
Renton
Dinner 6:00 p.m.
Program 6:30 p.m.
SEPTEMBER 22 | TUESDAY
OCT Analysis of Nerve and Macula
Drs. Meng Lu and Richard Lee
Seattle
Dinner 6:00 p.m.
Program 6:30 p.m.
Please send us your thoughts about our
continuing education efforts: Reach us at
800-826-4631, or [email protected]. Thank
you for sharing your comments.
association since the hypothesis fails to explain the presence of pseudotumor in
obesity’s absence. Two other popular theories of etiology target stenosis of the
transverse cerebral sinuses and pathogenesis based on levels of vitamin A in the
cerebrospinal fluid.
Signs and Symptoms
Patients present to the office most commonly with a diffuse and non-specific
headache. Transient vision loss, peripheral visual disturbances, and pulsatile
tinnitus are often reported. Horizontal diplopia due to compression of the sixth
nerve could be a presenting factor as well.
Optic disc edema is the hallmark sign of pseudotumor cerebri. The papilledema is
most often bilateral but can have asymmetrical presentation. Disc hemorrhages,
obscuration of retinal vascularization leaving the optic nerve, and striae of the
peripapillary retina can be present in more severe cases. While an enlarged blind
spot on perimetry can be an early finding, if left untreated, papilledema can lead to
optic atrophy and permanent field loss.
Diagnosis and Treatment
Official diagnosis of pseudotumor is often made via referral to a neurologist. An MRI
is ordered to rule-out space-occupying lesions to start. If no cause for the suspected
elevation of intracranial pressure is discovered, then lumbar puncture is
subsequently ordered to confirm the diagnosis. General treatment of pseudotumor
involves lowering the intracranial pressure to alleviate symptoms and to prevent
potential vision loss. This is often done medically through use of oral carbonic
anhydrase inhibitors. Weight loss of about 5-10% has been found to improve signs
and symptoms and to reduce risk of recurrence. Optic nerve sheath fenestration
and cerebrospinal fluid shunting are the most commonly used surgical procedures if
systemic medications do not achieve a desired therapeutic effect.
References:
Whiting AS, Johnson LN. Papilledema: clinical clues and differential diagnosis. Am Fam Physician.
1992 Mar;45(3):1125-34.
Yri HM, Wegener M, Sander B, Jensen R. Idiopathic intracranial hypertension is not benign: a longterm outcome study. J Neurol. 2012 May;259(5):886-94.