Papilledema

Dr Ben Wild

Overview

Our vision comes from light waves stimulating retinal photoreceptors and these photoreceptors transferring their signals through a multitude of other cells to the ganglion nerve cells. These ganglion cells bunch together and form the optic nerve. The optic nerve then sends the signal to the occipital lobe in the brain where vision is interpreted and recognized.

An image of a healthy retina and optic nerve.

Papilledema refers to the swelling of both optic nerves due to increased intra-cranial pressure (pressure in the skull leading to swelling of the brain). Intra-cranial pressure is regulated by the flow of cerebrospinal fluid between the brain and spinal cord. Any issue that affects how much fluid is created, how much is re-absorbed into the body, or the amount of free space there is in the skull can affect the pressure. Pressure changes usually cause headaches and sometimes, elevated intra-cranial pressure, can actually cause bilateral (both eyes) 6th nerve palsies leading to double vision.

An image of a healthy retina and a swollen optic nerve.

Signs and Symptoms

Signs

Early	Mild optic nerve reddening, mild optic nerve swelling.
Established	Normal vision to slightly decreased vision, severely red optic nerve, swollen optic nerve, broken blood vessels around the nerve, retinal folds around the nerve, swollen veins around the nerves.
Chronic	Decreased vision, large blind spots, white non-functioning nerve.

Symptoms

Headaches from elevated intra-cranial pressure can occur at any time of the day but are worse when elevating from a reclined position, on head tilt, coughing, and in rare cases, there are no headaches. Episodes of nausea, drowsiness, mild to no vision issues, double vision.

Causes and Risk Factors

Causes

Increased intra-cranial pressure from idiopathic intracranial hypertension (IIH), elevated pressure of unknown cause often linked to weight gain, closed off brain ventricles (born like this, tumors, aneurysms, etc.), increased fluid from brain bleed, decreased absorption due to infection (meningitis), stroke, trauma, severely elevated blood pressure, side effects of birth control, certain antibiotics or other medications, and more.

Risk Factors

Poor health, overweight.

Prevention and Treatment

Prevention

There are no known preventative measures other than a healthy lifestyle.

Treatments

After confirming elevated intra-cranial pressure through brain imaging and lumbar puncture (measure the pressure of cerebrospinal fluid as it is extracted from the spinal cord):

· Lose weight.

· Discontinue medications that may be causing the condition.

· Acetazolamide pills to decrease production of cerebrospinal fluid.

· Diuretic (blood pressure) medication to remove excess fluid.

· Brain surgery to remove masses or create shunts for better cerebrospinal fluid flow.

Prognosis

Patients with papilledema usually do not suffer any long term visual defects unless it is not diagnosed or treated properly at first onset. If the optic nerve swelling takes too long to resolve, permanent blind spots start to form and visual acuity may be affected.