H47.11-13; H47.141-143 Papilledema

Papilledema is optic disc swelling that is secondary to elevated intracranial pressure.  Vision is usually preserved with acute papilledema, despite other causes of optic disc swelling.  Papilledema almost always presents as a bilateral phenomenon and may develop over hours to weeks.

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The main goal of the diagnostic evaluation in a patient with papilledema is to accomplish the following:

• Determine the etiology of the papilledema
• Identify and exclude any differential diagnosis
• Determine the monitoring schedule and prescribe a treatment program specific to the etiology

Patient History

Patients with papilledema may present with any of the following abnormal signs and sypmtoms:

• Sudden onset of unilateral vision loss
• Pain with eye movements
• Relative afferent pupillary defect

DIAGNOSTIC TESTS

The following diagnostic tests are used to determine the extent of structural and functional damage from papilledema:

Refraction

• Measurement of visual function / visual acuity helps determine improvement of vision as the inflammation resolves

Visual Field Examination

• A visual field defect can be noted around the blind spot and the extent of edema corresponds to the visual field defect
• There may be an overall reduction in retinal sensitivity seen as well

Color Vision Examination

• Patients can also have a decrease in color perception especially red hues appear dimmer

Extended Ophthalmoscopy

• Helps evaluate optic disc morphology and look for elevation of optic nerve
• Assist with documenting abnormal structural changes to the optic disc

Fundus Photography

• Another means to evaluate optic disc morphology and elevation of optic nerve
• It can also assist in document abnormal structural changes to the optic disc

Retinal Scanning Laser

• Provides detail of the excavation of the optic disc

Right Eye xxx xxx Left Eye xxx xxx Both Eyes xxx xxx

Pupillary Examination

An afferent pupillary defect may be noted if the condition is both significant and asymmetric.

• RAPDx automated pupillary examination
• Assessment of pupillary response amplitude and velocity
• Index of defect numbers above 0.30 are considered abnormal
• Abnormal amplitude in the left eye indicates an afferent pupillary defect is present

Visual Evoked Potential Testing

The visual evoked potential (VEP) is an objective electric sign of visual pathway function and its parameters are sensitive to abnormalities in the visual system.  Measuring the conduction speed and magnitude of the neural response from the eye to the cortex can be helpful is assessing early changes in glaucoma.  Although not diagnostic of glaucoma, abnormal VEP test results in addition to other abnormal clinical findings can assist in making the difficult diagnosis of early glaucomatous damage.

• VEP testing evaluates the integrity of the afferent visual sensory system
• The procedure can be accomplished with the EvokeDx Testing Device manufactured by Konan Medical

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Optic Papillitis Mild swelling and elevation of the optic disc Not typical of optic neuritis associated with multiple sclerosis

Perineuritis

This type of optic neuritis is characterized by an inflammation of the optic nerve sheath.  In this condition, the optic nerve is spared and vision loss is mild to moderate.  Perineuritis usually affects older people and is commonly associate due to infectious or inflammatory conditions (e.g., sarcoidosis).  Perineuritis is not associated with multiple sclerosis.

Neuroretinitis

This type of optic neuritis may occur at any age.  It is characterized by concomitant swelling of optic disc and macula.  In severe presentation, exudates form around the macula to give the appearance of a macular star.  Neuroretinitis is not associated with multiple sclerosis.

Optic Nerve Drusen xxx xxx

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1.  Gossman M.  Papilledema.  Medscape/EMedicine.  6 Oct 2015.  http://emedicine.medscape.com/article/1217204-overview#showall.  Last accessed October 15, 2015.