PAPILLOEDEMA

Ans. is ‘a’ i.e., lntubation; `b’ i.e., Oxygenation; ‘c’ i.e., CT Scan

o The child in question with fever, unconsciousness & papilloedema, probably suffering from complicated meningitis/ encephalitis. Papilloedema is uncommon in uncomplicated meningitis & should suggest a more chronic process, such as the presence of an intracranial abscess, subdural empyema or occlusion of a dural venous sinus.

Emergenc^y & critical care management of a comatose child with intracranial hypertension :

The main goals of care include optimizing cerebral blood flow, cerebral perfusion pressure & minimizing factors that can aggravate neurological injury or trigger intracranial pressure elevation. General measures are :

1)         Assess the Airway, Breathing & Circulation (ABC) -* Intubation, oxygen etc.

2)         Assess & treat for immediately correctable causes of coma, like hypoglycemia, dyselectrolytemia etc.

3)         Assess the depth of coma with Glassgow coma scale.

4)         Assess & treatment of raised intracranial pressure with Mannitol, Hypertonic saline solutions.

5)         Antiseizure medications.

Neuroimaging : A CT scan may provide information about the cause of altered mental status & the presence of intracranial hypertension, however a normal CT scan does not rule out raised ICP. MRI is also helpful for early changes.

7)         Lumber puncture helpful for diagnosis & treatment of CNS infective causes. In an unconscious child with potential raised ICP, the decision is controversial with some authors stating that the risks of herniation for outweighs the benefit of knowing the pathogen from an early lumber puncture.

8)         Choice of empiric broad-spectrum antibiotic, till confirmatory tests available.

9)         Dextrose containing hypotonic IVF should be avoided & enteral feed started at the earliest.

10)        Others like steroids, Barbiturates etc.

Ans. is ‘d’ Midline posterior fossa tumour
“The classical triad of headache, nausea and vomiting, and papilledema is associated with midline or infratentorial tumors”.

Symptoms due to raised ICT –> These are mainly caused by midline posterior fossa tumor —> Medulloblastoma.

o Headache                                                  o Nausea                                              o Drowsiness

o Vomiting (usually in the morning)                 o Personality changes                            o Papilledema

o Diplopia / blurred vision                              o Irritability

Note – Brain-stem tumors are also posterior fossa tumors, but they do not present with increased ICT.

C i.e. Sudden painless loss of vision

• In papilloedema there is painless gradually progressive loss of vision which is usually bilateralQ which occurs after a long time only when optic atrophy sets in.
• “Visual acuity is not affected by Papilloedema unless it is severe, long standing, or accompanied by macular edema & haemorrhage”-Harrison’s P 169
• In contrast, in papillitis there is U/L sudden & marked painful loss of vision with ocular tenderness at insertion of MR & SRQ (medial & superior rectus), which is accompanied by pain on ocular movements, pulfrich phenomenon & RAPD Q.

B i.e. Disruption of neurofilament

The pincipal pathophysiology of optic disc swelling is blockage of axoplasmic tranportQ. It shows signs of edema without inflammation with collection of extra-cellular fluidQ. The nerve fibre of the optic nerve head are also swollen.

C i.e. Severe loss of vision
In papilloedema there is painless gradually progressive loss of vision (negligible ie usually not severeQ) which is usually bilateralQ which occurs after a long time only when optic atrophy sets in. So, Papilloedema ultimately leads to postneuritic optic atrophyQ and visual loss is not a feature of Acute Papilloedema

B i.e. Sudden loss of vision

A i.e. Benign intracranial hypertension

B i.e. Foster-Kennedy Syndrome
The Foster Kennedy syndrome consists of ipsilateral anosmia, ipsilateral optic atrophy, and contralateral papilledema. It is usually caused by an anterior fossa meningioma

Ans. Obliteration of physiological cup of the optic disc

Ans. Site of tumour

Ans. Medulla oblongata

Ans. Vision is impaired

Ans. Sudden painless loss of vision

Ans. Disruption of neurofilament

Ans. is ‘b’ i.e., Blurring of disc margin
Blurring of disc margin is earliest sign. Vision is normal initially. In 25% of patients visual symptoms occur only in advanced severe papilloedema, when optic atrophy sets in. Typically, there is recurring brief episodes (transient) of visual obscurations (Amaurosis fugax) lasting less then 30 seconds, in which vision turns grey or blacks, sometimes decribed as if a veil has fallen over the eyes. The symptoms usually affect both eyes at once as papilloedema is bilateral. Central vision is affected late in the disease. Initially there is enlargement of blind spot and progressive contraction of the visual field (visual field becomes smaller). Complete blindness sets in eventually. Thus, characteristically there is gradually progressive painless loss of vision.

Ans. is ‘b’ i.e., Blurring of the disc margin 

Ophthalmoscopic signs of papilloedema

• The blurring of disc margin (first sign)
• Venous:- Engorgement, congestion, loss of pulsation
• Hyperemia of the disc with capillary dilatation.
• Filling of the physiological cup with gradual obliteration of physiological cup.
• Gradual elevation of the disc (mushroom or dome-shaped) with sharp bending of vessels over its margins.
• Cotton- wool spots (soft exudates) and both flame-shaped (superficial) and punctate (deep) haemorrhages
•  Macular fan or macular star due to hard exudates.
• Late findings in long-standing (vintage) papilloedema:- Markedly elevated disc with champagne cork appearance, post neuritic optic atrophy, corpora amylacea deposits on disc margin, generalized retinal pigmentation