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

[Lorcan Butler]

here is the classic inferior nasal you asked about.

View attachment 45917
View attachment 45916

well done, and why is it this quadrant? and how can you interpret the VF plot to aid your differential diagnosis between pap and pseudo?

 

[Lorcan Butler]

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?

thanks for your input today Jeffrey.

 

[Jeffrey Kiener]

https://pubmed.ncbi.nlm.nih.gov/6638133/

Abstract​

Idiopathic intracranial hypertension (pseudotumor cerebri) produces loss of visual field and visual acuity. We conducted a retrospective study of 12 patients (all female, ranging in age from 6 to 44 years) using computerized visual field analysis. In seven of the 12 patients, the visual field loss appeared to be permanent, and follow-up was too short for the final outcome to be determined in two others. The visual field defects were those known to be associated with optic disk lesions. The most common were blind spot enlargement (all 12 cases), isopter constriction (nine cases), and loss on the nasal side of the visual field (seven cases), especially in the inferonasal quadrant. Four patients had diminished visual acuities. The reversibility of the visual field defects was correlated with the presence (nonreversible) or absence (reversible) of ophthalmoscopic signs of chronic papilledema. Because visual loss is reversible if treatment is begun before the onset of the optic disk changes associated with chronic papilledema, patients with idiopathic intracranial hypertension should be monitored carefully with frequent perimetric and visual acuity testing.
PubMed Disclaimer

 

[Jeffrey Kiener]

https://journals.lww.com/ijo/fulltext/2011/59020/visual_fields_in_neuro_ophthalmology.5.aspx​

...Vision loss is the most feared complication of IIH with at least 10% of patients progressing to blindness from IIH.[16] The visual field defects that result from papilledema in IIH are “disc-related defects” and are similar to those found in glaucoma.[17] Visual field losses may be identified in as many as 96% of patients using disease-specific perimetric strategies such as the Armaly-Drance strategy for Goldmann perimetry or SAP. The most common defects seen in IIH are blind spot enlargement, generalized constriction, and loss of the nasal visual fields, especially inferonasal [Fig. 2].[18] Other common field defects described include inferior altitudinal loss, superonasal and superotemporal loss,[19] arcuate defects, and scotomas (central, cecocentral, and paracentral).[20]


Plenty of "whats" but not a lot of "whys".
https://www.sciencedirect.com/science/article/abs/pii/S0039625719302516

Conclusions​

Despite the significant knowledge gained throughout the decades on the role of IOP and ICP in the pathogenesis of papilledema, IIH, glaucoma, and more recently SANS, gaps in our knowledge remain to be discovered and elucidated. The TLPD—the anatomical intersection of IOP and ICP—plays a significant role in pathological changes of the optic disk and vision loss. The biomechanics of the LC and posterior sclera have been the subject of intense study given the capabilities of OCT imaging.

 

[Lloyd Pate]

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?

Start with answering why papilledema is not present in a greater percentage of kids with increased intracranial pressure than adults.

Papilledema is estimated to be absent in 5.7% [1] of adult cases and 27% to 48% of all pediatric cases [2-4].
1. Digre, K.B., et al., A comparison of idiopathic intracranial hypertension with and without papilledema. Headache, 2009. 49(2): p. 185-93.
2. Faz, G., I.J. Butler, and M.K. Koenig, Incidence of papilledema and obesity in children diagnosed with idiopathic ''benign'' intracranial hypertension: case series and review. J Child Neurol, 2010. 25(11): p. 1389-92.
●
3. Balbi, G.G.M., et al., Pseudotumor cerebri in childhood and adolescence: data from a specialized service. Arq Neuropsiquiatr, 2018. 76(11): p. 751-755.
●
4. Agraz, D., et al., Clinical features of pediatric idiopathic intracranial hypertension. Clin Ophthalmol, 2019. 13: p. 881-886.


Look at the blood supply and were it has the least vessels.

 

[Lorcan Butler]

https://pubmed.ncbi.nlm.nih.gov/6638133/

Abstract​

Idiopathic intracranial hypertension (pseudotumor cerebri) produces loss of visual field and visual acuity. We conducted a retrospective study of 12 patients (all female, ranging in age from 6 to 44 years) using computerized visual field analysis. In seven of the 12 patients, the visual field loss appeared to be permanent, and follow-up was too short for the final outcome to be determined in two others. The visual field defects were those known to be associated with optic disk lesions. The most common were blind spot enlargement (all 12 cases), isopter constriction (nine cases), and loss on the nasal side of the visual field (seven cases), especially in the inferonasal quadrant. Four patients had diminished visual acuities. The reversibility of the visual field defects was correlated with the presence (nonreversible) or absence (reversible) of ophthalmoscopic signs of chronic papilledema. Because visual loss is reversible if treatment is begun before the onset of the optic disk changes associated with chronic papilledema, patients with idiopathic intracranial hypertension should be monitored carefully with frequent perimetric and visual acuity testing.
PubMed Disclaimer

thanks for sharing, small sample size but relevant information .

Start with answering why papilledema is not present in a greater percentage of kids with increased intracranial pressure than adults.

Papilledema is estimated to be absent in 5.7% [1] of adult cases and 27% to 48% of all pediatric cases [2-4].
1. Digre, K.B., et al., A comparison of idiopathic intracranial hypertension with and without papilledema. Headache, 2009. 49(2): p. 185-93.
2. Faz, G., I.J. Butler, and M.K. Koenig, Incidence of papilledema and obesity in children diagnosed with idiopathic ''benign'' intracranial hypertension: case series and review. J Child Neurol, 2010. 25(11): p. 1389-92.
●
3. Balbi, G.G.M., et al., Pseudotumor cerebri in childhood and adolescence: data from a specialized service. Arq Neuropsiquiatr, 2018. 76(11): p. 751-755.
●
4. Agraz, D., et al., Clinical features of pediatric idiopathic intracranial hypertension. Clin Ophthalmol, 2019. 13: p. 881-886.

hi Jeffrey the presenting signs and symptoms between the adult cohort and paediatric cohort are completely different. Not comparing like for like. Thanks for sharing.

 

[Lloyd Pate]

well done, and why is it this quadrant? and how can you interpret the VF plot to aid your differential diagnosis between pap and pseudo?

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?

Case Reports

Am J Ophthalmol

. 1980 Jul;90(1):1-10.
doi: 10.1016/s0002-9394(14)75069-x.

Nasal visual field loss with intracranial lesions of the optic nerve pathways​

R S Manor, G E Ouaknine, S Matz, M N Shalit

• PMID: 7395947
• DOI: 10.1016/s0002-9394(14)75069-x

Abstract​

Five patients developed nasal visual field defects as a result of involvement of the intracranial portion of the optic nerves. The cause in each patient, respectively, was as follows: (1) dolichoectatic carotid arteries, (2) optochiasmatic arachnoiditis, (3) meningioma of the olfactory groove, (4) pituitary apoplexy, and (5) pituitary chromophobe adenoma. The common factor in these cases was probably impaired circulation in the prechiasmal arterial anastomotic network. The nasal visual field loss present in these cases was characterized by a pattern similar to that seen in glaucoma but with impairment of visual acuity. The superior nasal visual field was usually normal and the lower temporal visual field often defective.
PubMed Disclaimer

 

[Matt Judd]

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 .

which OCT make has enhanced depth imaging OCT? never heard of it

thanks

 

[Lorcan Butler]

which OCT make has enhanced depth imaging OCT? never heard of it

thanks

hi Matt it's Heidelberg Engineering OCT. There's an international association of world renowned ophthalmologists and neuro-ophthalmologists called the Optic Disc Drusen Consortium who specialise in imaging of ODD/ONHD. they have said that EDI now supercedes Ultrasound B as the Gold Standard imaging technique. Hope that helps.

 

[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 !!

These article sum up my practices.

"This case emphasizes the importance of detailed clinical history taking in children with presumed pseudopapilloedema. In the setting of IIH, the finding of ODD may lead to diagnostic confusion causing delay in appropriate management. Enquires must be made with regard to neurological symptoms prior to accepting the diagnosis of pseudopapilloedema."

https://www.nature.com/articles/6701430

"This case emphasizes the importance of detailed clinical history taking and enquires must be made regarding neurological symptoms prior to accepting the diagnosis of pseudopapilledema."

https://journals.lww.com/jcor/fullt...ce_of_optic_disc_drusen_and_idiopathic.8.aspx

IIH is a diagnosis of exclusion and disc drusen does not exclude it.

 

[Matt Judd]

I've come to getting fields on anyone with elevated disk as I put it. just too difficult to say drusen

however, when I use the red-free filter and can clearly see drusen, and they have literally no symptoms, I move on.

headaches symptoms etc etc w/ elevated swollen looking disks, I investigate every time

to put in perspective, someone I know was seen by the neuro OMD recently. the doctor had fields, OCTs, and everything else. and STILL ordered a B scan as he wasnt certain. and this guy is good and been around for a while

 

[Lloyd Pate]

I've come to getting fields on anyone with elevated disk as I put it. just too difficult to say drusen

however, when I use the red-free filter and can clearly see drusen, and they have literally no symptoms, I move on.

headaches symptoms etc etc w/ elevated swollen looking disks, I investigate every time

to put in perspective, someone I know was seen by the neuro OMD recently. the doctor had fields, OCTs, and everything else. and STILL ordered a B scan as he wasnt certain. and this guy is good and been around for a while

Symptoms and clinical presentation are what matters the most.

I also run OCTs and look at the RPE line angle, enface for Patton's folds, and Ganglion cell complex among other things.

When in doubt, scan.

 

[Lloyd Pate]

Lorcan,

Out of curiosity, about how many papilledema cases do you see a week in your clinic?

 

[Lorcan Butler]

I've come to getting fields on anyone with elevated disk as I put it. just too difficult to say drusen

however, when I use the red-free filter and can clearly see drusen, and they have literally no symptoms, I move on.

headaches symptoms etc etc w/ elevated swollen looking disks, I investigate every time

to put in perspective, someone I know was seen by the neuro OMD recently. the doctor had fields, OCTs, and everything else. and STILL ordered a B scan as he wasnt certain. and this guy is good and been around for a while

Old school order older tests Matt, nothing wrong with it. It's a bit like the contentious issue of SVP and papilledema. Older MDs love it , younger MDs don't even rate it. So changing of the guard brings new techniques and thought processes. thanks Matt

 

[Lorcan Butler]

Lorcan,

Out of curiosity, about how many papilledema cases do you see a week in your clinic?

very few thankfully, what about you?

Symptoms and clinical presentation are what matters the most.

I also run OCTs and look at the RPE line angle, enface for Patton's folds, and Ganglion cell complex among other things.

When in doubt, scan.

good job

 

[Lorcan Butler]

I've come to getting fields on anyone with elevated disk as I put it. just too difficult to say drusen

however, when I use the red-free filter and can clearly see drusen, and they have literally no symptoms, I move on.

headaches symptoms etc etc w/ elevated swollen looking disks, I investigate every time

to put in perspective, someone I know was seen by the neuro OMD recently. the doctor had fields, OCTs, and everything else. and STILL ordered a B scan as he wasnt certain. and this guy is good and been around for a while

look for Partons Lines on RF, always temporal with supero or infero

 

[Jeffrey Kiener]

Matteo: If you see elevated discs and get fields are you doing it to rule out papillitis vs. papilledema?

Or you make the dx of papilledema and are trying to gauge the visual fallout?

 

[Matt Judd]

Old school order older tests Matt, nothing wrong with it. It's a bit like the contentious issue of SVP and papilledema. Older MDs love it , younger MDs don't even rate it. So changing of the guard brings new techniques and thought processes. thanks Matt

would love to have access to the heidelberg you mentioned.

 

[Matt Judd]

Matteo: If you see elevated discs and get fields are you doing it to rule out papillitis vs. papilledema?

Or you make the dx of papilledema and are trying to gauge the visual fallout?

for me, papilledema is usually bilateral. not necessarily symmetric but bilateral. and papillitis is usually in on eye.

I sent out for 2 MRIs today and used papilledema unspecified.

Whats become a little strange is the imaging center now wants the CPT code for the MRI. I find that weird tbh

 

[Lorcan Butler]

would love to have access to the heidelberg you mentioned.

it's fantastic, hospital grade technology in primary care

for me, papilledema is usually bilateral. not necessarily symmetric but bilateral. and papillitis is usually in on eye.

I sent out for 2 MRIs today and used papilledema unspecified.

Whats become a little strange is the imaging center now wants the CPT code for the MRI. I find that weird tbh

all sounds correct there , well done .

 

[Lloyd Pate]

very few thankfully, what about you?

good job

I saw 5 new papilledema cases yesterday.

 

[Lorcan Butler]

Matteo: If you see elevated discs and get fields are you doing it to rule out papillitis vs. papilledema?

Or you make the dx of papilledema and are trying to gauge the visual fallout?

papillitis as in a variant of Optic Neuritis is usually unilateral . Diabetic Papillitis in DR can be bilateral but you'd get that in history taking . majority of pap is bilateral . thanks

 

[Lorcan Butler]

I saw 5 new papilledema cases yesterday.

I'm happy for you Lloyd.

 

[Lloyd Pate]

look for Partons Lines on RF, always temporal with supero or infero

Have you tried the VRI en face view? It makes them easier to see especially if you do an OCTa that has higher resolution.

 

[Lloyd Pate]

I'm happy for you Lloyd.

It is fun but scary at the same time. I have staffed a dedicated neuro-ophthalmology clinic for over 13 years. I have taught in one neuro-ophth program and 3 neurology programs. I hope to figure out what I am doing one day.

 

[Lorcan Butler]

It is fun but scary at the same time. I have staffed a dedicated neuro-ophthalmology clinic for over 13 years. I have taught in one neuro-ophth program and 3 neurology programs. I hope to figure out what I am doing one day.

sounds like you're already getting there haha

 

[Lloyd Pate]

sounds like you're already getting there haha

Every time I think I am, they come up with something showing what I thought I knew was wrong. As I tell my students, learning never ends. However, I really wonder why I do this sometimes since it scares me to death at times.

 

[Lorcan Butler]

Every time I think I am, they come up with something showing what I thought I knew was wrong. As I tell my students, learning never ends. However, I really wonder why I do this sometimes since it scares me to death at times.

Keep on going, keep on training, sounds like you're doing a fantastic job !

 

[Matt Judd]

Lorcan, who is your football team?

 

[Lorcan Butler]

Lorcan, who is your football team?

not football sorry, rugbyhead Munster and Ireland

 

[Lloyd Pate]

not football sorry, rugbyhead Munster and Ireland

Now that is a British sport worth playing. Did you play?

 

[Lorcan Butler]

Now that is a British sport worth playing. Did you play?

I'm an Irish man , yep played all the way through school and college but as you know life , work and family gets in the away sometimes. What about you , what's your sport , favourite team ?

 

[Lloyd Pate]

I'm an Irish man , yep played all the way through school and college but as you know life , work and family gets in the away sometimes. What about you , what's your sport , favourite team ?

That is neat. You can't say anything bad about a rugby player.

I grew up in Texas, so I played football. I also ran track, and since I was a country boy, I rode bulls. I mainly did multiple martial art disciplines for over 35 years.

https://www.bayarearugby.com/history

It is funny that I actually I dabbled in rugby as a youngster. Got the scar in my forehead as a reminder. We didn't know what we were doing, but had fun doing it. No one had ever played rugby before, so we read the books. It would have made you die laughing.