1. Sleuthing The Swollen Optic Disk
A non-specific Finding….. …..Warrants a Thorough Evaluation

2. Speaker Disclaimers Corporate Compensation: None
Investments/Interests: None

4. Unilateral or Bilateral?
Critical First Test:
Unilateral or Bilateral?
Unilateral  “optic neuropathy”
Bilateral  “papilledema”
Until proven otherwise

5. Malignant Hypertension

6. “Post-op Vision Loss, OU”

8. Critical 2nd Test:
TRUE Edema vs PSEUDOedema

9. Check Blood Pressure Critical 3rd Test: Malignant Hypertension?
With or Without HTN retinopathy!

10. Critical 4th Test: REVIEW of SYSTEMS Health Hx. Medications Hx.
Symptoms

11. Polycythemia

12. Is there PAIN???
Ocular?
Head?

13. B.P. spike with N.A.I.O.N. “HURTS behind my eye”

14. What Do The Visual Fields Look Like?
OD, OS, or OU?
RNFL “bundle defect”
Central or Ceco-central defect
Enlarged Blindspot and overall depression

15. Causes of TRUE Disk Edema

16. #1 ISCHEMIA
1st Anterior Ischemic Optic Neuropathy 2nd C.R.V.O. (venous stasis) 3rd Malignant Systemic Hypertension 4th Carotid-Cavernous Sinus Fistula (rare) 5th Diabetic Papillopathy (rare)

17. “Healthy 23 y.o. male”

18. #2: BLOCKAGE of RETROGRADE FLUID FLOW
1st Axonal and Intraneuronal C.S.F.
- Raised intracranial pressure
+ Bilateral + “Papilledema”
2nd Venous Blood
- C.R.V.O.
3rd Axonal and Intraneuronal C.S.F.
- Optic Nerve Tumor
- Orbital Mass Effect

19. #2: BLOCKAGE of RETROGRADE FLUID FLOW 4th Bilateral Venous Outflow - C
#2: BLOCKAGE of RETROGRADE FLUID FLOW 4th Bilateral Venous Outflow - C.C.S.F. - cerebral venous sinus thrombosis - right heart failure - pulmonary hypertension - sleep apnea - superior vena cava syndrome - jugular vein occlusion - dural fistula

20. 1st Papillitis 1st Anterior Optic Neuritis
#3: INFLAMMATION
1st Papillitis 1st Anterior Optic Neuritis

21. #4: OPTIC DISK TRAUMA
Optic Nerve Contusion

22. #5: TOXICITY and NUTRITIONAL NEUROPATHY
“Moonshine Retinopathy”
Drug Addiction
Annorrhexia
Bulimia

23. #6: DRAMATIC I.O.P. CHANGE
Acute Glaucoma
Ocular Hypotony

24. Non-Edematous (“without fluid”) Disk Elevation & Thickening
Causes of
Non-Edematous (“without fluid”) Disk Elevation & Thickening

25. #1: OPTIC DISK IRREGULARITIES
#1) Disk Drusen #2) Crowded Disk #3) Tilted Disk #4) Myelinated Nerve Fibers

26. #2: LEBER’S HEREDITARY OPTIC NEUROPATHY
Suspect in any case of BILATERAL “idiopathic” optic neuropathy
Inherited mitochondrial disease
Passed on by Mom
Affects both genders
Affects all ages
Diagnosis: Genetic Testing

27. #3: OPTIC DISK INFILTRATION
#1) Metastasis - breast - lung #2) Primary Tumor #3) Leukemia #4) Lymphoma #5) Sarcoidosis

28. Key Findings
TRUE DISK EDEMA

29. Look For: Elevation Peripapillary Retinal Sheen
Circumferential Retinal Folds
Radiating Retinal Folds
Whitening of the peripapillary retinal nerve fiber layer

32. Retinal Folds?

35. Blurry Disk Margins
SmallLarge Vessel Obscuration
Venous Bloating & Tortuosity
Peripapillary/Papillary Hemorrhages
Juxtapapillary Exudates

36. Fluid Pockets/ “Bags” on OCT
Leakage (not “late staining”) on Fluorescein Angiography

37. TRUE Disk Edema…..
Now What????

38. Or Is it Optic Neuropathy ???????
Is it Papilledema
Or Is it Optic Neuropathy ???????

39. LATERALITY
Unilateral vs
Bilateral vs
Bilateral, Asymmetric

40. VISUAL ACUITY
Reduced “early on…” vs
Not reduced until late

41. COLOR VISION
Reduced “early on….” vs
Not reduced until late

42. CONTRAST SENSITIVITY
Grossly Reduced vs
NOT Reduced

43. VISUAL FIELDS OPTIC NEUROPATHY PAPILLEDEMA Central depression
Macular bundle depression
Arcuate pattern depression
Altitudinal pattern depression
PAPILLEDEMA
Enlarged blindspots
Scattered nasal field defects
Overall peripheral depression

44. T.V.O. ASSESSMENT Transient Visual Obscurations
One eye?
Both eyes?
“How do changes in posture affect your vision?”
“What if you bend over?”

45. RAISED INTRACRANIAL PRESSURE
SYNDROME

46. 1) Look carefully at BOTH disks!!!
Papilledema almost always present
Spontaneous Venous Pulsation almost always absent

47. 2) Look carefully at SYMPTOMS!
Headache
Transient Visual Fluctuations
Pulsatile Tinnitus
Nausea
Vomiting
Horizontal Diplopia—worse at Far
Focal neurologic symptoms elsewhere in the body

48. Compare that to: EDEMATOUS OPTIC NEUROPATHY
Symptoms primarily ocular/visual
Usually Hx of underlying disease
May be “classic symptoms” of that associated disease
Cranial arteritis
Lyme disease
Cat scratch disease

50. You now DO suspect Papilledema….what next?
Preferred Practice Patterns advise: IMAGING
IS MANDATORY!

51. CT of Head (advisable) Large masses
DETECTS:
Large masses
Intracranial hemorrhaging (fresh blood)
Hydrocephalus

52. …….But I still think my patient has papilledema…….Now What?
Uh, Oh. CT is “WNL”
…….But I still think my patient has papilledema…….Now What?

53. MRI of BRAIN with contrast
DETECTS:
Intracranial masses
Infiltrates
Cerebral venous thrombosis (+/-)
Meningeal pathologies

54. CT and MRI are Normal but Papilledema still suspected?
LUMBAR PUNCTURE
With CSF opening pressure
Normal < 200mm
Questionable mm
Elevated > 250mm
With CSF laboratory analysis
Normal = idiopathic intracranial hypertension likely
Abnormal: chronic meningitis, spinal cord tumor, etc.

55. Diagnosis still in Doubt?
R/O VENOUS SINUS THROMBOSIS
MRV of HEAD and NECK

56. Diagnosis still in Doubt?
Etiology must be a systemic venous return issue……
Extensive cardiovascular workup indicated
“Emphasis on venous return pathologies”