Makindo Medical Notes

Related Subjects: |Brain tumour s |Astrocytomas |Brain Metastases |Tuberous sclerosis |Turcot's syndrome |Lhermitte Duclos Disease |Oligodendroglioma |Acute Hydrocephalus |Intracranial Hypertension |Primary CNS Lymphoma (PCNSL)

👁️ Papilloedema is swelling of the optic disc due to raised intracranial pressure (ICP). It requires emergency referral to ophthalmology/neuro services and urgent brain imaging (including MRV/CTV to exclude cerebral venous sinus thrombosis). The mechanism of optic nerve damage is axoplasmic flow stasis causing intraneuronal ischaemia → untreated cases risk permanent vision loss.

📍 About

• Represents venous outflow obstruction, inflammation, or raised ICP.
• Optic disc swelling due to impaired axoplasmic transport.
• May occur with raised CSF pressure, intracranial mass, or systemic causes.

⚠️ Causes

• Raised ICP:
  • Brain tumours (supra- and infratentorial).
  • Abscess, oedema.
  • Haemorrhage (ICH, SAH, SDH, EDH).
  • Encephalitis, hydrocephalus.
  • Cerebral venous sinus thrombosis (CVT).
  • Sarcoidosis, Guillain–Barré (↑ CSF protein).
  • Idiopathic intracranial hypertension (IIH).
• Malignant hypertension.
• Retro-orbital lesions (e.g. cavernous sinus thrombosis).
• Optic neuritis / uveitis (inflammatory).
• Ischaemia (e.g. accelerated HTN).
• CO₂ retention.

🔎 Pseudopapilloedema

• Optic disc drusen or congenital disc anomalies.
• Disc infiltration (inflammatory or neoplastic).
• Down syndrome (associated anomalies).

Assessing optic discs can be challenging. Mydriasis is not usually required, but 0.5% tropicamide can be used if necessary. Always document if dilating drops are used.

🩺 Clinical Features

• Visual acuity often preserved until late — but document carefully.
• Early sign = loss of spontaneous venous pulsation.
• Optic disc looks swollen/oedematous, with blurred margins.
• Grey/blurred vision, transient visual obscurations, diplopia.
• Fundoscopy: hyperaemia, flame haemorrhages, cotton-wool spots.
• Visual field loss (enlarged blind spot, peripheral constriction).
• Systemic: headache, nausea, vomiting, pulsatile tinnitus.

🧠 Differentials

• Pseudopapilloedema (disc drusen, anomalies).
• Optic neuritis (painful, ↓ acuity early, RAPD present).
• Anterior ischaemic optic neuropathy.

🔬 Investigations

• CT/MRI + venogram (CTV/MRV): First step → rule out mass lesion & venous thrombosis.
• If imaging excludes mass lesion → LP with opening pressure for ICP assessment.

💊 Management

• Hypertension: Aggressive BP control in malignant HTN.
• Mass lesion: Urgent referral to neurosurgery.
• CVT: Anticoagulate + neurology input.
• IIH: Weight reduction, acetazolamide, neuro-ophthalmology review, regular visual field monitoring.
• Other optic nerve/eye disease: Ophthalmology referral.

📌 Exam Tip

Papilloedema = raised ICP until proven otherwise. 👉 Always do neuroimaging before lumbar puncture to avoid coning. Fundoscopy: swollen disc, blurred margins, venous engorgement, haemorrhages. Vision preserved early — differentiates from optic neuritis.

📚 References

• RCPE Neuro-ophthalmology guidance
• NICE NG127: Stroke and TIA (investigation of raised ICP).