Optic Discs: Papilledema [95187-NO / 95188-NO]

[Lorcan Butler]

OPTIC DISCS: PAPILLEDEMA
Lorcan Butler, BSc (Hons), MCOptom

Papilledema can be a very challenging condition to detect especially in its early stages. This presentation will go through signs & symptoms utilizing multi-modal imaging techniques with guides to referrals and urgency of referrals. Best Practice techniques and clinical pearls will be given during the presentation.

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CEwire2025 Live Dates: January 26, April 6, June 8, September 7, 2025
Time: 10:00AM - 11:00AM ET
Location: Virtual Room 1
Credit Hours: 1
Synchronous COPE ID: 95187-NO
Asynchronous COPE ID: 95188-NO
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[DOWNLOAD HANDOUT] and DISCUSS THIS LECTURE & ASK QUESTIONS BELOW!

 

[Lorcan Butler]

Looking forward to giving you some Clinical Pearls and Key Takeaways you can bring back to your practice. Delighted to answer any questions you may have on this tricky topic of being able to differentiate papilledema from pseudopapilledema.
Whether it be adult vs children, symptoms, OCT, VF , Color Vision, referrals i would be happy to answer any queries you may have.

 

[Steve Silberberg]

Looking forward to giving you some Clinical Pearls and Key Takeaways you can bring back to your practice. Delighted to answer any questions you may have on this tricky topic of being able to differentiate papilledema from pseudopapilledema.
Whether it be adult vs children, symptoms, OCT, VF , Color Vision, referrals i would be happy to answer any queries you may have.

Great having you from across the pond. Enjoy the conference!

 

[Lorcan Butler]

Maybe I can start the ball rolling in this thread to interested viewers. What is the hardest part that ODs find in this difficult area. Signs, symptoms, VF, OCT, what to say to their, patient, how to explain it? What is your biggest pinch point, let me do the heavy lifting on this for you.

 

[Lloyd Pate]

Maybe I can start the ball rolling in this thread to interested viewers. What is the hardest part that ODs find in this difficult area. Signs, symptoms, VF, OCT, what to say to their, patient, how to explain it? What is your biggest pinch point, let me do the heavy lifting on this for you.

The fact that you can have increased intra-cranial pressure without papilledema and symptoms can be subtle or absent.

 

[Lloyd Pate]

OCT of IIH here.

 

[Lorcan Butler]

The fact that you can have increased intra-cranial pressure without papilledema and symptoms can be subtle or absent.

Thank you so much Lloyd for posting. Yes I agree it can happen but it does tend to be an extremely rare variant. The majority of people with elevated ICP and IIH do tend to fit a classical phenotype in gender and age and 90% will be symptomatic. Like any ocular condition we try to be cognisant of all variants and outliers but the majority group, what you would expect to find in your clinic, is what we're trying to approach here. Thank you very much for your insight.

 

[Lloyd Pate]

Thank you so much Lloyd for posting. Yes I agree it can happen but it does tend to be an extremely rare variant. The majority of people with elevated ICP and IIH do tend to fit a classical phenotype in gender and age and 90% will be symptomatic. Like any ocular condition we try to be cognisant of all variants and outliers but the majority group, what you would expect to find in your clinic, is what we're trying to approach here. Thank you very much for your insight.

The above patient was a skinny 7 year old.

 

[Lorcan Butler]

Thanks Lloyd for posting this in this thread. it's so good that other practitioners are seeing this too. OCT is like any adjunct test we utilise in our screening. It is a tool that needs to be interpreted by the clinician like any other adjunct test. We are now using multi-modal retinal imaging and combining all of our adjunct test results to guide us in our detection, diagnosis and referral decisions. We cannot rely on one test result, it needs to be contextual and related to symptoms, signs, and absence/presence of associated ocular & neurological signs associated with the condition .Thanks again.

 

[Lorcan Butler]

The above patient was a skinny 7 year old.

wow great catch. there does tend to be a marked difference in the assoc risk factors between adult & paediatric cohorts . Obesity, female gender, larger BMI tends to be well known risk factors in adults but it doesn't translate to paediatric. Especially in pre -pubertal children normal BMI children can get IIH and papilledema just as much. The obesity and gender predisposition tends to affect post pubertal.

 

[Lloyd Pate]

wow great catch. there does tend to be a marked difference in the assoc risk factors between adult & paediatric cohorts . Obesity, female gender, larger BMI tends to be well known risk factors in adults but it doesn't translate to paediatric. Especially in pre -pubertal children normal BMI children can get IIH and papilledema just as much. The obesity and gender predisposition tends to affect post pubertal.

Correct. Unfortunately, a lot of clinicians don't look for it in the atypical patient. I have found IIH in skinny, males over 60.

 

[Lloyd Pate]

Thanks Lloyd for posting this in this thread. it's so good that other practitioners are seeing this too. OCT is like any adjunct test we utilise in our screening. It is a tool that needs to be interpreted by the clinician like any other adjunct test. We are now using multi-modal retinal imaging and combining all of our adjunct test results to guide us in our detection, diagnosis and referral decisions. We cannot rely on one test result, it needs to be contextual and related to symptoms, signs, and absence/presence of associated ocular & neurological signs associated with the condition .Thanks again.

For multi-modal imaging are using OCT and camera?

 

[Lorcan Butler]

For multi-modal imaging are using OCT and camera?

yes you're using colour fundus photography red free, auto fluorescence , infra red, in conjunction with Visual Fields .Optomap Optos Ultra wide fields and Ultrasound B scan and more recently classified as the Gold Standard technics is Enhanced Depth Imaging OCT image acquisition . You may not have them all but throw everything you got at it .

 

[Lorcan Butler]

Correct. Unfortunately, a lot of clinicians don't look for it in the atypical patient. I have found IIH in skinny, males over 60.

you're not wrong Lloyd. The outliers are out there especially more now with Iatrogenic presentations. Great catch well done and keep up the good work

 

[Lloyd Pate]

yes you're using colour fundus photography red free, auto fluorescence , infra red, in conjunction with Visual Fields .Optomap Optos Ultra wide fields and Ultrasound B scan and more recently classified as the Gold Standard technics is Enhanced Depth Imaging OCT image acquisition . You may not have them all but throw everything you got at it .

I have all of those. Some docs will have trouble because we can not get paid for both OCTs and photos at the same visit.

 

[Lloyd Pate]

yes you're using colour fundus photography red free, auto fluorescence , infra red, in conjunction with Visual Fields .Optomap Optos Ultra wide fields and Ultrasound B scan and more recently classified as the Gold Standard technics is Enhanced Depth Imaging OCT image acquisition . You may not have them all but throw everything you got at it .

I use enhanced depth too and wonder what you are looking at with it.

 

[Lorcan Butler]

I use enhanced depth too and wonder what you are looking at with it.

EDI (enhanced depth imaging) Heidelberg Engineering has the ability to go deeper into the Optic Nerve than other OCT which stop at the ON head. Therefore better ability to identify hidden/buried Drusen to differentiate pap from pseudopap. Normal OCT & FAF only show visible ONHD at the ON surface but can't go deeper. Total Game changer . Supercedes Ultrasound B as the new " Gold Standard" .Hope that helps

 

[Lloyd Pate]

EDI (enhanced depth imaging) Heidelberg Engineering has the ability to go deeper into the Optic Nerve than other OCT which stop at the ON head. Therefore better ability to identify hidden/buried Drusen to differentiate pap from pseudopap. Normal OCT & FAF only show visible ONHD at the ON surface but can't go deeper. Total Game changer . Supercedes Ultrasound B as the new " Gold Standard" .Hope that helps

Is the presence of drusen a good thing? Newer research shows drusen may be formed by papilledema.

Front. Neurol., 13 December 2021
Sec. Neuro-Ophthalmology
Volume 12 - 2021 | https://doi.org/10.3389/fneur.2021.789673
Optic Nerve Drusen Is Highly Prevalent Among Children With Pseudotumor Cerebri Syndrome

Neuroophthalmology. 2016 Aug; 40(4): 171–180.
Published online 2016 Jul 1. doi: 10.1080/01658107.2016.1198917
Increased Prevalence of Optic Disc Drusen after Papilloedema from Idiopathic Intracranial Hypertension: On the Possible Formation of Optic Disc Drusen
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123006/

 

[Lorcan Butler]

Is the presence of drusen a good thing? Newer research shows drusen may be formed by papilledema.

Front. Neurol., 13 December 2021
Sec. Neuro-Ophthalmology
Volume 12 - 2021 | https://doi.org/10.3389/fneur.2021.789673
Optic Nerve Drusen Is Highly Prevalent Among Children With Pseudotumor Cerebri Syndrome

Neuroophthalmology. 2016 Aug; 40(4): 171–180.
Published online 2016 Jul 1. doi: 10.1080/01658107.2016.1198917
Increased Prevalence of Optic Disc Drusen after Papilloedema from Idiopathic Intracranial Hypertension: On the Possible Formation of Optic Disc Drusen
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123006/

good question. ONHD are a normal physiological congenital condition . they both can be and cannot be associated with pap. Our job as ODs is to differentiate between both as they can co-exist and be a co -morbidity. I talk exactly about this in my presentation. Are you booked on ?

 

[Steve Silberberg]

The fact that you can have increased intra-cranial pressure without papilledema and symptoms can be subtle or absent.

The use of OCT findings when other conditions exist such as wet or dry AMD make the GCC analysis hard if not impossible

 

[Lorcan Butler]

The use of OCT findings when other conditions exist such as wet or dry AMD make the GCC analysis hard if not impossible

I go through GCC-IPL analysis on the presentation and how to interpret pap from pseudopap

 

[Lorcan Butler]

Here is a question for the group discussion? what non- visual symptoms should you be on the lookout for ? what red flag symptoms should increase your risk of suspicion ?

 

[Mike Alvarez]

Maybe I can start the ball rolling in this thread to interested viewers. What is the hardest part that ODs find in this difficult area. Signs, symptoms, VF, OCT, what to say to their, patient, how to explain it? What is your biggest pinch point, let me do the heavy lifting on this for you.

The biggest problem is always differentiating pseudo papilledema from true papilledema, knowing when to pull the trigger and send the patient to the ER.

Here is a question for the group discussion? what non- visual symptoms should you be on the lookout for ? what red flag symptoms should increase your risk of suspicion ?

Pulsatile tinnitus and headaches, especially upon awakening.

 

[Lloyd Pate]

Here is a question for the group discussion? what non- visual symptoms should you be on the lookout for ? what red flag symptoms should increase your risk of suspicion ?

Nuchal rigidity, Pulsatile tinnitus, tinnitus, hearing loss, headaches upon awakening or when bending over or straining, vomiting, dizziness or coordination problems, lack of energy or sleepiness to name a few.

 

[Lloyd Pate]

The biggest problem is always differentiating pseudo papilledema from true papilledema, knowing when to pull the trigger and send the patient to the ER.

That is a big problem. I have had patients with no symptoms and extremely elevated ICP, and I have had patients with extremely elevated ICP and no papilledema.

 

[Jay Desai]

That is a big problem. I have had patients with no symptoms and extremely elevated ICP, and I have had patients with extremely elevated ICP and no papilledema.

Have you seen cases of 6th nerve palsy with elevated ICP, but negative papilledema?

 

[Lloyd Pate]

Have you seen cases of 6th nerve palsy with elevated ICP, but negative papilledema?

I saw a 17yo in active brainstem herniation with no papilledema. Her speech was soft and airy. She had emergency surgery that day.

 

[Jeffrey Kiener]

My problem with increased intracranial pressure is that:
1. the in-office diagnostics are vague, such as OCT and TVF and even ophthalmoscopy
2. the imaging is a.) expensive and b.) hard to access without making a big fuss.

I'm going to make a big fuss on a rip-roaring case, no doubt.
But subtle signs? Subtle symptoms? It's hard to pull the trigger on an MRI/MRV unless you have something tangible to go on.

 

[Lloyd Pate]

My problem with increased intracranial pressure is that:
1. the in-office diagnostics are vague, such as OCT and TVF and even ophthalmoscopy
2. the imaging is a.) expensive and b.) hard to access without making a big fuss.

I'm going to make a big fuss on a rip-roaring case, no doubt.
But subtle signs? Subtle symptoms? It's hard to pull the trigger on an MRI/MRV unless you have something tangible to go on.

Over all, 17% of brain MRIs are normal. So, maybe you should not be scared to order them because it will be normal. Look at the whole picture, symptoms and findings on your tests and the trust your gut feelings.

To make life more fun the diagnostic error rate on MRIs is 10–26%, so you can not completely trust the report. Trust your findings over the MRI report.

You are always free to call me.

 

[Lloyd Pate]

good question. ONHD are a normal physiological congenital condition . they both can be and cannot be associated with pap. Our job as ODs is to differentiate between both as they can co-exist and be a co -morbidity. I talk exactly about this in my presentation. Are you booked on ?

I don't worry about drusen anymore since papilledema can cause it. I concentrate on ruling out elevated ICP. I feel that you are chasing the wrong rabbit when you concentrate on drusen since it does not rule out increased ICP.

 

[Lorcan Butler]

I don't worry about drusen anymore since papilledema can cause it. I concentrate on ruling out elevated ICP. I feel that you are chasing the wrong rabbit when you concentrate on drusen since it does not rule out increased ICP.

thanks for that but I have to disagree with you. So you just refer everybody in your practice then with Drusen. Very strange !!

 

[Lorcan Butler]

The biggest problem is always differentiating pseudo papilledema from true papilledema, knowing when to pull the trigger and send the patient to the ER.

Pulsatile tinnitus and headaches, especially upon awakening.

thanks Mike, yes fully agree 100% and that's the whole premise of my presentation. Giving you clues and signs that maybe you weren't aware of before. Giving you confidence next time so you will know when to pull that trigger. Thanks for contributing.

 

[Lorcan Butler]

My problem with increased intracranial pressure is that:
1. the in-office diagnostics are vague, such as OCT and TVF and even ophthalmoscopy
2. the imaging is a.) expensive and b.) hard to access without making a big fuss.

I'm going to make a big fuss on a rip-roaring case, no doubt.
But subtle signs? Subtle symptoms? It's hard to pull the trigger on an MRI/MRV unless you have something tangible to go on.

thanks Jeffrey. We can't rely on one in-office imaging modality, it's a combination of them all which paints the overall picture. Age, gender, BMI, symptoms which are both visual and non visual should pre warn you with a risk of suspicion even before you look Into their eyes. Thanks for contributing

 

[Lorcan Butler]

thanks Mike, yes fully agree 100% and that's the whole premise of my presentation. Giving you clues and signs that maybe you weren't aware of before. Giving you confidence next time so you will know when to pull that trigger. Thanks for contributing.

Ataxia, difficulty with gait, balance, neck pain, lethargy , sleeping more, lack of
of concentration, feeling spaced out. thank you

 

[Lorcan Butler]

Lets talk about Visual Field Defects in papilledema . enlargement of the BS is going to be first. What is the next defect ? What quadrant is affected next and why? What other characteristics of the VF defect can help you ascertain if it's pap or pseudopap?

 

[Lloyd Pate]

thanks for that but I have to disagree with you. So you just refer everybody in your practice then with Drusen. Very strange !!

No, I order imaging on anyone with drusen that I think has increased intracranial pressure. I do not rule out high ICP or papilledema because of the presence of drusen.

I order my own MRIs and MRVs then order a lumbar puncture if needed. Then they go to neurology or neuro-surgery.

 

[Lloyd Pate]

Lets talk about Visual Field Defects in papilledema . enlargement of the BS is going to be first. What is the next defect ? What quadrant is affected next and why? What other characteristics of the VF defect can help you ascertain if it's pap or pseudopap?

here is the classic inferior nasal you asked about.

 

[Lloyd Pate]

However, here is another IIH field from a patient with no papilledema.

 

[Lloyd Pate]

and another

 

[Jeffrey Kiener]

Does the question become: where is the structural weakness in the individual's optic nerve head, and therefore the specific vision loss??

Tilted disc has one kind of weak spot?
Oblique insertion another?
Large posterior scleral foramen is protective?
Small posterior scleral foramen is like my collar on my shirt this morning?