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Important questionsin papilloedema ?

Prof. K. Vengala Rao

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What causes OD to swell ?

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1. Pre laminar axon distension2. Extra cellular oedema

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Why pre laminar axons swell ?

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Blocked axoplasmic flow atlaminar gate

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What causes block inaxoplasmic flow ?

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1.Compression of axons

2.Ciliary ischemia

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Why is the ON so vulnerable

to raised ICP ?

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Ciliary flow to laminar region isweak (Choroidal steal)

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Can you distinguish

Ophthalmoscopically

papilloedema from other causes of

disc oedema ?

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Yes and NoPapilloedema is not segmental

Papilloedema is not pallid

Papilloedema is not monoocular (usually)

It can be asymmetricalDisc is more swollen than NFL

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What gets confused withpapilloedema ?

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Congenital OD elevation

Acquired causes that look like papilloedema

IONIncreased BP

Increased blood sugar (Papillopathy)

Indentation (Orbital mass)Inherited (LHON)

Intoxication (Methanol)

Infiltration (Cancer)Inflammation (Peri neuritis, Sarcoid, Posterior

Uveitis)

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Why does papilloedema look

like other causes of acquired

oedema ?

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Axoplasmic stasis is common to all

causes of disc oedema

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How to distinguish fromother causes ?

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Visual function is well preserved

Except in acute papilloedemaMacular oedema

Atrophic papilloedema

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Why is vision relativelypreserved in acute

papilloedema ?

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Elevated ICP impairs

axoplasmic flow less than local

causes

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Why does vision fall in

chronic papilloedema ?

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Shut down of all axoplasmic flow

(slow and fast)

Compression of ciliary vessels with

infarction

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Can you predict whether vision

will fail in papilloedema ?

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Not very well

Risk factors for vision failureSystemic Hypertension

High ICPPreexisting optic neuropathy

Disc pallor

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Can acute elevated ICP exist

with out papilloedema ?

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YES.!

Hayreh30% have papilloedema after 24

hrs90% have papilloedema after 5

days

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Does papilloedema reflect

current ICP elevation ?

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Not necessarilyIt takes papilloedema a longtime to go away after ICP

has normalized

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Can chronic elevated ICP

exist with out

papilloedema ?

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Not very often.!

Chronically elevated ICP canproduce unilateral (or very

asymmetrical) papilloedemaChronic elevated ICP can exist

with normal ODs (patients with

headache)

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Why might papilloedema not

occur in chronic ICP elevation ?

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Pressure rise is slow

No communication betweenintracranial and intra orbital

subarachnoid space

Atrophic ON

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What is the significance of

finding papilloedema ?

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ICP is (or was) elevated

If you do not find papilloedema,ICP has not been chronically

elevated

Ventriculomegaly does not mean

raised ICP

Small ventricle do not mean ICP isnormal

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What is the best surgical

treatment for papilloedema ?

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ONSF if there is fall of vision

LP shunt or VP shunt if headacheis severe

There is no comparative study sofar

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Thank

You