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Papilledema

Jonathan A. Barnett

Background

  • Papilledema refers to edema of the optic nerve due to increased intracranial pressure

  • Ophthalmology is often consulted to rule out papilledema in patients who fit the “Idiopathic Intracranial Hypertension (IIH)” profile, or with patients with other reasons for high ICP

Presentation

  • Symptoms of increased ICP: headaches that vary with position (often worse with bending over), nausea, vomiting, neck stiffness/meningismus, pulsatile tinnitus, fevers/chills

  • Visual symptoms of papilledema: transient visual obscurations, dimming of vision, blurry vision, loss of color vision/red desaturation, loss of peripheral vision, scotoma.

Evaluation and Management

  • Consult Ophthalmology and Neurology if concerned for papilledema. Neurosurgery should be involved if there is concern for shunt failure or other neurosurgical problem.

  • Ophthalmology / Neurology will advise on what imaging to order (usually MRI / MRV brain with and without contrast, + MRI Orbits with and without contrast and fat suppression)

  • If no contraindications after imaging, obtain LP with opening pressure, with CSF sent for cells, protein, glucose, and infectious/neoplastic workup where appropriate

  • Ophthalmology / Neurology may recommend initiation of PO or IV acetazolamide (Diamox). These may be contraindicated or need to be renally dosed if the patient has chronic kidney disease.