The document discusses optic disc swelling and pseudopapilledema. It begins by differentiating between true optic disc swelling versus pseudo swelling. It then discusses evaluating cases based on whether they are unilateral or bilateral, and whether vision is normal or abnormal. Causes of optic disc swelling and pseudopapilledema are provided for different clinical scenarios. Management approaches such as medical treatment, surgical options, and lifestyle modifications are summarized. Throughout, examples of patient presentations are given to demonstrate clinical decision making.

1. Dr Clare Fraser

2.  Swelling of the optic disc occurs when there is
hold up of axonal transport at the level of the
lamina cribrosa
 = appearance is identical in apparently
different pathological processes

3.  True vs pseudo
 Unilateral vs bilateral
 Normal vs abnormal vision

4. The first question to ask

5.  True
 Blurred disc margin
 Obscured vessels
 Hyperaemic
 Loss SVP (20% normal
patients)
 Pseudo
 Vessels visible
crossing margin
 Anomalous branching
 No micro-vascular
congestion

6.  Drusen
 Hypermetropia
 Crowded discs
 Hyaloid remnants
 Myelinated nerve fiber layer

14. Less helpful but worth considering

15. UNILATERAL
 Local
 Optic neuritis
 Vascular occlusion
 Infiltrative
BILATERAL
 Systemic
 Disc drusen
 Infectious optic neuritis
 Papilledema
 Malignant hypertension
 Toxicity

16. The final question to ask

17.  Papilloedema
 preserved visual function
 Papillitis secondary to local causes
 Poor visual function
 Ischaemia
 visual loss is determined by the occurrence of disc
infarction

18.  Optic nerve
 Optic neuritis
 Ischaemic ON
▪ arteritic AION
▪ NA-AION
 Compressive orbital
 Infiltrative
 LHON
 Vascular
 CRVO
 malignant hypertension
 Ocular
 Uveitis / posterior
scleritis
 Hypotony

19. Characteristic Patients
Female
Caucasian
Age
Ocular pain
Pain on eye m'ment
Optic disc
Normal
Swollen
No retinal or disc Hb
Vision
6/6 or better
6/6 - 6/12
6/15 – 6/240
CF or LP
NPL
77%
85%
32
92%
87%
65%
35%
85%
11%
25%
49%
13%
3%

20.  90% will have 6/12 vision or better
 75% will have 6/9 vision or better
 40% develop Multiple Sclerosis in 10 years
 30% have a relapse of optic neuritis in 5 years

26.  Leukaemia
 Lymphoma

29.  Papilledema
 brain tumour
 thrombosis
 meningitis
 malignant hypertension
 pseudo-tumor cerebri
 IIH
 Optic nerve
 perineuritis
 diabetic papillopathy
 optic neuritis (early)*
 Vascular
 CRVO

37.  There are no clinically diagnosable causes of
optic disc swelling with normal vision
 All require some form of investigation
 Urgency depends of speed of symptom onset
 Simple things first
 Blood pressure
 Temperature (meningitis)
 Urine analysis (haematuria in vasculitis)

38.  Systemic hypertension
 Space occupying lesion
 Dural venous sinus thrombosis
 Meningitis
 Pseudotumour cerebri / IIH

39.  MRI and MRV with contrast
 CT and CTV is sufficient
 Referral for lumbar puncture

40. Pseudotumour cerebri

41.  Headache
 Pulsatile tinnitus
 Transient visual obscurations
 Double vision
 Incidental finding at an optom visit

42.  Daily diffuse non-pulsating
 Any location
 Worse lying flat or straining
 Wakes up with headache, clears after 30-60
minutes
 Can sound migrainous – pulsating, unilateral
 Increased ICP worsens all other types of
headache tendencies

43.  Signs and symptoms of increased ICP
 Headaches, nausea, vomiting,TVO, papilledema
 No localising focal neurological signs
 Except CNVI palsies
 CSF opening pressure >25cm H20
 Normal constituents
 Normal neuroimaging
 Exclude mass lesion, venous sinus thrombosis
 No other underlying cause identifiable

44.  “No other underlying cause identifiable”
 So I prefer to use the term
 “pseudotumour cerebri”
 Especially if the patient has BMI <25
 Until I am happy there is no underlying cause
 As a reminder to keep looking for one

45.  Drugs
 Vit A, tetracyclines, steroids, some NSAIDS,
cyclosporin, OCP
 Diseases
 COPD, sleep apnea, renal failure, anaemia

46.  Need urgent attention if
 rapid increase in symptoms
 acuity loss

47.  Obese women
 Dose relationship between BMI and risk
 Lower body (gynaecoid) adiposity
 Childbearing age

48.  Increased risk of IIH with 5-15% weight gain1
 even if BMI remains <30
 A return to a BMI similar to the time of first
presentation = risk for IIH recurrence2
 even a 6% weight gain is a risk of recurrence
 BMI associated with more severe visual loss3
 Even a 10% weight loss can be sufficient
1. Daniels et al. Profiles of obesity in IIH. AmJO 2007;143.
2. Ko M et al.Weight gain in IIH. Neurology 2011;76.
3. Szweka A et al. IIH obesity vs vision. JNO. July 2012

49.  Seen in 80-100% of
adult IIH patients
 There are no studies in
children

50.  Alleviate symptoms
 Headache
 Preserve vision
 While the patient loses weight

51. Based on
 Duration of symptoms
 Speed of symptom onset (?fulminant)
 Evaluation of visual function
 Patient characteristics
 Male
 Black race
 Morbid obesity
 Anemia
 OSA

52.  1-2g daily in divided dose
 Decreases CSF production
 Side effects
 Parasthesia, altered taste, lethargy
 Low K+
 If not tolerated
 topiramate
 bendroflumethiazide

53.  Optic nerve sheath fenestration
 Fulminant onset
 Other treatments failing to prevent progressive
vision loss
 Depends on local resources

54.  Produces a rapid reduction in pressure on the
optic nerve head
 Reduces papilledema
 Improves vision in operated eye
 +/- fellow eye
 Does not decrease ICP
 ? Causes local fistula formation

55.  Acute and rapidly progressive vision loss
 Headache, no response to other therapy
 Lumbar drain (transient)
 Ventriculo-peritoneal shunt
 Lumbar-peritoneal shunt

56.  If increased pressure across stenosis
 Reduces cerebral venous pressure
 Reduces ICP and improves symptoms
 Still not widely accepted in international
community, frequently done in Sydney

58.  IIH is a diagnosis of exclusion
 Pathophysiology is still not understood
 There are no RCTs to guide management

60.  Seen by an optometrist, patchy HVF changes

61.  24 year old with reduced vision one eye

62.  34 yo presents with bilateral vision loss to
6/36 right and 6/12 left

63.  Referred ?disc swelling

64.  13 yo girl, 3 week history of severe headaches,
nausea and vision loss to HMs in each eye

65.  After lumbar puncture, optic nerve sheath
fenestration and medical treatment, 6/36 OU