A. Intracranial space occupying lesions
B. Malignant hypertension
C. Chronic meningitis
D. All of the above
Ans is D All of the above
(Condition shown: Papilledema- Swollen pink disc, Congested vessels, Blurred margins)
- Optic disc swelling that is secondary to elevated intracranial pressure.
It occurs secondary to raised intracranial pressure which may be associated with following conditions:
- Congenital conditions include aqueductal stenosis and craniosynostosis.
- Intracranial space-occupying lesions (ICSOLs).
- Intracranial infections such as meningitis and encephalitis .
- Intracranial haemorrhages. Cerebral as well as subarachnoid haemorrhage..
- Obstruction of CSF absorption via arachnoid villi .
- Tumours of spinal cord .
- Idiopathic intracranial hypertension (IIH) also known as pseudotumour cerebri.
- Systemic conditions include malignant hypertension, pregnancy induced hypertension ,cardiopulmonary insufficiency, blood dyscrasias and nephritis.
- Diffuse cerebral oedema from blunt head trauma may causes papilloedema.
In majority of the cases with raised intracranial pressure, papilloedema is bilateral.However, unilateral cases as well as of unequal change do occur with raised intracranial pressure. A
few such conditions are as follows:
- Foster-Kennedy syndrome. It is associated with olfactory or sphenoidal meningiomata and frontal lobe tumours. In this condition, there occurs pressure optic atrophy on the side of lesion and papilloedema on the other side (due to raised intracranial pressure).
- Pseudo-Foster-Kennedy syndrome. It is characterised by occurrence of unilateral papilloedema associated with raised intracranial pressure (due to any cause) and a pre-existing optic atrophy (due to any cause) on the other side.
Clinical features of papilloedema can be described under four stages: early, fully developed, chronic and atrophic.
1. Early (incipient) papilloedema
- Symptoms are usually absent and visual acvity is normal.
- Pupillary reactions are normal.
- Ophthalmoscopic features : : (i) Obscuration of the disc margins (nasal margins are involved first followed by the superior, inferior and temporal) (ii) Blurring of peripapillary nerve fibre layer. (iii) Absence of spontaneous venous pulsation at the disc (appreciated in 80% of the normal individuals). (iv) Mild hyperaemia of the disc. (v) Splinter haemorrhages in the peripapillary region may be present.
- Visual fields are fairly normal.
2. Established (fully developed) papilloedema
- Symptoms. Patient may give history of transient visual obscurations in one or both eyes, lasting a few seconds, after standing. Visual acuity is usually normal.
- Pupillary reaction remain fairly normal,
- Ophthalmoscopic features : (i)Apparent optic disc oedema is seen as its forward elevation above the plane of retina; usually up to 1-2 mm (1 mm elevation is equivalent to +3 dioptres). (ii) Physiological cup of the optic disc is obliterated. (iii) Disc becomes markedly hyperaemic and blurring of the margin is present all-around. (iv) Multiple soft exudates and superficial haemorrhages may be seen near the disc. (v) Veins becomes tortuous and engorged.(vi) In advanced cases, the disc appears to be enlarged and circumferential greyish white folds may develop due to separation of nerve fibres by the oedema. (vii) Rarely, hard exudates may radiate from the fovea in the form of an incomplete star.
- Visual fields show enlargement of blind spot.
3. Chronic or long standing (vintage) papilloedema
- Symptoms. Visual acuity is variably reduced depending upon the duration of the papilloedema.
- Pupillary reactions are usually normal
- Ophthalmoscopic features . In this stage, acute haemorrhages and exudates resolve, and peripapillary oedema is resorbed. The optic disc gives appearance of the dome of a champagne cork. The central cup remains obliterated. Small drusen like crystalline deposits (corpora amylacea) may appear on the disc surface.
- Visual fields. Blind spot is enlarged and the visual fields begin to constrict.
4. Atrophic papilloedema
- Symptoms. Atrophic papilloedema develops after 6-9 months of chronic papilloedema and is characterized by severely impaired visual acuity.
- Pupillary reaction. Light reflex is impaired.
- Ophthalmoscopic features :It is characterised by greyish white discoloration and pallor of the disc due to atrophy of the neurons and associated gliosis. Prominence of the disc decreases in spite of persistent raised intracranial pressure. Retinal arterioles are narrowed and veins become less congested. Whitish sheathing develops around the vessels.
- Visual fields. Concentric contraction of peripheral fields becomes apparent as atrophy sets in.