The first picture is a normal eye. The second has Papilledema. Note the blurred disk margins, swelling, and hemorrhage seen in the second picture.
What is Papilledema?
Papilledema is the swelling of the Optic Nerve as it enters the back of the eye. When you have (sudden) visual changes, unusual headache or unexplained nausea and vomiting; your doctor may look into your eyes with an Opthalmoscope. This handheld instrument shines a bright light into your eyes for the Doctor to better view. Changes in appearance of the Optic Nerve and the blood vessels that pass through it can be seen through the Opthalmoscope and might be related to your symptoms.
Important Note- You do not have to have Papilledema to have PTC.
The anatomy of the Optic Nerve makes it a sensitive marker for problems inside the brain. This nerve is a thick cord that connects the back of each eyeball and it's retina to the brain. In its short span between the brain and the eye, the Optic Nerve's whole surface is bathed by Cerebral Spinal Fluid (CSF). Although this fluid protects the nerve from sudden movement, even slight increases in the pressure of this fluid can affect the Optic Nerve (because it can compress the nerve around it's whole circumference in a "choking" manner). It is when this nerve is exposed to high pressure, or when it develops inflammation of its own that it can bulge into the back wall of the eyeball resulting in Papilledema.
Some important causes of increased CSF pressure and Papilledema are brain tumors and brain infections (brain abscess, meningitis, or encephalitis). At the time of diagnosis, 80 percent of people who have brain tumors have some evidence of Papilledema as a consequence. A pressure increase resulting from bleeding or from very high blood pressure can also result in Papilledema.
One condition that can cause increased pressure in the CSF is Intracranial Hypertension (IH). This condition seems to be triggered at times that the body is making adjustments to hormonal changes, such as pregnancy, the start of birth control pill use, the first menstrual periods and menopause. The name Pseudotumor was originally given to this condition because it results in symptoms similar to those caused by a tumor in the brain.
Papilledema can also be caused by inflammation inside the Optic Nerve, called Optic Neuritis. Multiple Sclerosis is the most common cause of Optic Neuritis.
Symptoms
Symptoms related to Papilledema are caused by the Increased Pressure and include visual disturbances, headache and nausea with vomiting. Twenty-five percent of people with advanced Papilledema develop some visual symptoms. Typically, the visual changes are recurring brief episodes lasting less than 30 seconds in which the vision turns gray or "blacks out," sometimes described as if a veil has fallen over the eyes. The symptoms usually affect both eyes at once. Visual blackouts often are triggered by a change in position, such as standing up very suddenly, or they may be triggered by coughing or straining within the chest or the abdomen. Occasionally, people with Papilledema can have an experience of flashing lights, often seen in an arc shape. Other visual changes occur over time, including a smaller field of vision with an enlarged blind spot. If not treated promptly and accurately, permanent visual changes and even blindness can occur.
Diagnosis
The front end of the Optic Nerve is visible at the back of the eye when your doctor or eye specialist looks through the pupil with an Opthalmoscope. The round front end is just over 1- 1/2 millimeters in size, but it is clearly seen with the magnifying lens that is built into this instrument. Normally, the end of the nerve, called the Optic Disk, has a crisp outline and is slightly indented. If the Optic Disk appears elevated and has a blurred outside margin, your doctor can diagnose Papilledema. The pressure within the nerve can cause congestion of the draining veins within your eye, and very tiny pulsations that are normally seen in the eye's veins tend to disappear. When Papilledema is severe, small red spots from local bleeding or spotty color changes on the retina from accumulated debris or from damaged retina cells may be present.
The physical exam also will include checking of your field of vision. Papilledema results in a wider blind spot for each eye (near the nose), and it narrows the peripheral vision. To check your visual field, your doctor may simply compare your visual abilities to his or her own by sitting across from you and moving fingers in and out of view. Visual fields can be tested more formally by an Ophthalmologist using vision grids.
Findings that alert your doctor to Papilledema should be treated as an emergency. It is appropriate to have a brain scan (CT or MRI) within 24 hours so that a brain tumor can be quickly ruled out.
If there is no abnormality on the brain scan, most patients will need to have a Lumbar Puncture (spinal tap, LP) performed so that the opening pressure of the CSF can be measured. IH is a common cause of Papilledema when the brain scan is normal.
Treatment
The choice of treatment for Papilledema depends on its cause.
IH can be treated with repeat LP's to take off excess spinal fluid, and/or medications may be prescribed. Some patients may require surgery if they do not respond well to initial treatment. Such surgery can include Optic Nerve Sheath Fenestration
(O.N.S.F),
a procedure local to the eye that helps facilitate drainage of extra fluid from the nearby CSF space. Additional surgical procedures may involve the placement of Shunts.
Because IH may be a chronic condition and has the potential to cause visual damage, close monitoring by an Ophthalmologist is an important part of the treatment plan.
Prognosis
You may have chronic Papilledema for months or years and still not develop significant visual loss. However, once visual loss begins to occur, it can quickly become permanent within days or weeks and requires urgent treatment.
