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By Prof. K.

Vengala Rao


Formen of monroe 3rd VENT Aqueduct of Syluius

4th VENT
Foramina of Majendi & Lushka




F.S.C.P. outflow .  Communicating Hydrocephalus  Non communication Hydrocephalus Obstruction to C.HYDROCEPHALUS Dilatation of Ventricles due to Raised I.

Clinical features of raised ICP Systemic : Headache Nausea and Vomiting Deterioration of Consciousness .

V. lasting few seconds Horizontal Diplopia due to 6th Palsy Visual Failure due to Post Papilloedema optic atrophy .Visual symptoms of raised ICP T.O.

L.F.S.O. .H.Pseudo Tumour Cerebri 5) Trauma . . 7) Hypersecretion :Tumours of choroidal Plexus 8venous sinus thrombosis .Etiology of papilledema 1) Obstruction of ventricular system Congenital and Acquired =hydrocephalus 2) S.Sub Arachnoid Haemorrage 3) Impairment of C. Trauma 4) I.H.I.Diffuse Cerebral Edema 6) Severe Systemic H. absorption Meningitis.T.A. S.

Classification of Papilloedema A) Early B) Established C) Chronic D) Atrophic Acute papilledema Chronic Papilledema .

Early Papilloedema No Visual Symptoms Hyperemia of O.N.F. Blurring of O.D. Blurring of R. Swelling of O.D.L.D. Flame shaped Haemorrhages Absence of Venous pulse Venous Dilatation .

No Papilloedema .Hyperemia Capillary Dilatation Early sign No Hyperemia .

N. Superficial leniar light reflex loss .Blurring of Peri – papillary R.L.F.

First seen near superior and inferior poles Hyreh – 1st sign is swelling .Swelling of O.D.

Temporal .Blurring of Margins No Value as single sign Nasal. Superior. Inferior.

N.Peri – papillary R. Haemorrages important Sign Rupture of Dilated Capillaries .F.L.

C. more than 200 mm 20% have no venous pulse normally Not a definite sign .P.Loss of Venous Pulse I.

Dilatation of Retinal veins

not an early sign

Summary of Early Papilloedema
Single finding is not diagnostic Frequent observation of the patient C.T or M.R.I. If there is doubt

Fully developed Papilloedema (Established)
More disc swelling Venus dilatation Splinter hemorrhages on O.D. and Retina M.A., Capillary Dilatation on O.D. Vessels obscured by Swollen N.F.L. Soft exudates Patton’s lines Hard exudates - macular fan Sub Hyaloid Haemorrages

Chronic Papilloedema Haemorrages and exudates resolve Cup obliterated Disc becomes gray Hard exudates on the disc N. atrophy .F.L.

Narrowing and sheathing of vessels Choroidal folds May occur in months or years Optico ciliary shunts Peripheral field loss .Post Papilloedemic Optic Atrophy Edema subsides Atrophy of O.D.

Unilateral or Asymmetric Papilloedema Usually bilateral Unilateral papilloedema may occur Congenital anomalies Brain abscess Damage to Optic Tract causes homonymous hemianopia with atrophy of nasal fibres causes band atrophy. In such cases if Papilloedema occurs it is seen in the upper and lower parts of the OD only. . TWIN PEAK PAPILLEDEMA Optic atrophy in one eye due to any cause does not develop papilloedema in that eye.


N in one eye & old A.I. Pseudo foster Kennedy syndrome acute A.N in other eye .N.O.O.Foster Kennedy Syndrome Frontal lobe and Olfactory groove tumors Optic atrophy on one side Papilloedema on other side Optic atrophy is due to pressure on O.I.

The opposite eye showed only an enlarged blind spot from disc swelling The CT showed a large meniningioma . The visual field showed a defect on the side of the tumor.Foster Kennedy Syndrome A case of Foster Kennedy syndrome with unilateral disc swelling in the left eye and relative pallor in the opposite right eye due to a meningioma.

This man has a case of pseudo-Foster Kennedy syndrome with unilateral disc swelling due to AION and the other eye has optic atrophy due to a previous bout of AION. .Pseudo foster Kennedy syndrome The most common cause of a Pseudo Foster Kennedy syndrome is old AION in one eye and a new AION in the other eye.

I.F.C.T. or M.A.R.T d) C.P. e) L.Diagnosis 1) Direct ophthalmoscopy with red free light 2) Indirect 3) If there is doubt a) F. B) Ultrasound c) O. if there is no mass lesions .

Dye leakage Micro aneurisms Late Dye leakage beyond O.D.D.FFA Capillary dilatation on O. margins .

F O.D.Differential Diagnosis Pseudo – papilloedema Congenital anomalies of optic disk        M.DRUSEN TILTED disk Disk hypoplasia Hyaloid remnants on OD Congenital fullness due to small scleral canal HYPERMETROPIC O.D .N.

OPTIC DISC DRUSEN O. This causes hazy appearance of disk margin But not the vessels Anomalous brancing of retinal vessels Peri papillary R.E dispersion Disc margin has scalloped appearance .D.D is not hyperemic.P.D accounts for most cases of pseudo edema O. surface micro vasculature is not dilated Blurring of disc margins is due to axoplasmic stasis in the axons deep in the optic disk.

O.M No treatment for O.V.D ..N Acute vision loss from peri papillary C.O Buried Drusen may resemble disk edema May cause peripheral field defects Acute vision loss due to A.D.V. Small calcific concretions present in 1 – 2 % of O.I.N.N Autosomal dominant transmission Bilateral could be asymmetrical May progress .OD DRUSEN contd..usually asymptomatic Occasionally T.

A .T scan of orbits without contrast Ultrasound B Scan F.Diagnosis of OD DRUSEN Funds examination Auto fluorescence C.F.

OD Drusen CT Scan B Scan Fundus Auto – fluoresceins red free photo .

Bilateral ONH hypoplasia Bilateral inferior field defects .

A) Tilted Optic nerves in high myope patient MNF B) Bi – temporal defects .

N. 5. 4.N .O.OD oedema due to other causes 1. And Papillitis Hypertension Infiltration of optic nerve L. 2. inflammation Diabetic Papillopathy Optic peri Neuritis Infiltrative neuropathy Compressive Neuropathy A. 7.O. 8. 9.I. I. 6.H. 3.O.

D And venous dilatation Central cup: present Haemorrhages.Differentiation between true and Pseudo .Papilloedema True O. exudates present Pseudo elevated yellowish white anomalous large vessels with multiple branches absent absent .D elevated Hyperemic Increased capillaries on O.

S. Decreased C. No neurological symptoms Papilledema Bilateral Normal V.A Normal C.C..N.V. present .D.V 4. Decreased V.Differentiation between ODE due to other causes from Papilloedema O.P 6th cranial nerve palsy pulsatile tinnitus. altitudinal 5. Field defects: central Arcuate.P 1.V Enlarged B.E due to O. Unilateral 2. T.A 3. Isolated or underlying Disease 6. nasal defect.O. constriction Symptoms of raised I.

P. is reduced .Development Develops from hours to months Resolution depends on how fast the I.C.

more serious More severe . loss of field Loss of colour vision or early parameters for loss of vision .Prognosis for Vision More rapid .Bad prognosis Pallor .Worse Prognosis Narrow arteries .Bad prognosis Loss of central vision.

F. Axonal swelling Distended S/A space .Pathology Abnormal protrusion of O.D. Lateral displacement of retina Folds of posterior retinal layers Haemorrages Focal necrosis of N.

Pathogenesis 1) Uncertain 2) Patency of Meningeal spaces is a must 3) Blockage of Meningeal spaces .no Papilloedema 5) Abnormal axonal transport .no Papilloedema 4) Optic atrophy .

Pathogenesis (contd)  Axoplasmic Transport  Orthograde – Retrograde  Fast Component – 500MM per Day  Slow Component – 2MM per Day .

N  This Obstructs axoplasm transport  Slow Component affected in Papilledema  Rapid Component in Ischemia.C.P. transmitted Into S.A.Pathogenesis (Contd…)  Obstruction to axoplasm transport  I. Space of O. Inflammation  Rapid component important for Synaptic transmission  Slow component for nutrition .

Mydriasis and LR Paralysis VISUAL Flashes T.V. nasal defects and later central 300 field is involved .O in one or both eyes precipitated by change of posture Untreated papilledema leads to visual loss Central V.Symptoms and Signs Non Visual: Headache Vomiting Bradycardia Loss of Consciousness Rigidity.A is normal until late Field changes : enlarged blind spot.

Hippocanpal Herniation .T. .Few seconds on change of posture cause .O.N.distended 3rd ventricle Ischemia of O.V.

S. Enlargement Arcuate scotoma Nasal defect Peripheral contraction .Field defects B.

Visual function Check blood pressure Refer to neuro centre .Responsibility of Ophthalmologist Papilledema is an emergency Workup : look for underlying neurological disease.

L Normal brain M. venous hypertension and I.I.S.R.F analysis should be performed .Evaluation of patient with papilloedema Neuro imaging is an emergency M.F opening pressure and C.I suggests Meningeal process.R.H L.I of brain with contrast is ideal C.O.P with C.T detects only i/c hamorrhage. hydrocephalus and large S.T scan with out contrast is useless C.S.

IC mass and Papilloedema Subtentorial mass causes papilloedema often Supratentorial mass .Papilloedema Less frequent Posterior cranial fossa tumors cause Papilloedema more often 80 % of brain tumors cause Papilloedema Gliomas cause Papilloedema in 76 % .

Grading of papilloedema         Lars frisen grading Grade 0 increased IC pressure very little If any disc swelling is seen Stage 1. elevation of disc margin 360 Blood vessels at disc margin not obscured Stage 3. superior and inferior borders Stage 2. C shaped blurring of nasal.elevation of entire disk with partial Obscuration of retinal vessels at disc margin .

Dome-shaped appearance with all vessels being obscured.) . (Sometimes called "champagne cork" swelling ? because of its dome shape.Grading of papilloedema (contd…)       Stage 4.F. complete obliteration of cup Complete obscuration of some vessels On the surface of the disc Small dilated capillaries on the disc Haemorrhages and N.L infarcts Stage 5.

Very little if any disc swelling is seen. .Grading Papilledema: Stage 0 GRADING PAPILLEDEMA We grade papilledema in order to tell us how severe it is. The most sensible grading scheme has been provided by Lars Frisen. STAGE 0: This woman had documented increased intracranial pressure of 340 mm water.

superior and inferior borders.Stage 1 = C-shaped blurring of the nasal. Also notice the chorio – pretinal folds (arrows) that eminate toward the macula (M) . Usually the temporal margin is normal.

Stage 2 = Elevation of the disc margin 360 degrees. Since the blood vessels at the disc margin are not swollen or obscured. this disc could be mistaken for pseudo-papilledema .

Here the vessels are partly obscured and make the development into stage 3 easier to call. .Stage 3 = Elevation of the entire disc with partial obscuration of the retinal vessels at the disc margin.

.Stage 4 = Complete obliteration of the cup and complete obscuration of at least some vessels on the surface of the disc. There may be small dilated capillaries on the disc that resemble telangiectasia. It is not the NFL infarcts or hemorrhages but the obscuration of the vessels themselves that makes this disc stage 4.

(Sometimes called "champagne cork" swelling ? because of its dome shape.Stage 5 = Dome-shaped appearance with all vessels being obscured.) .

One cannot afford to make any mistake in the diagnosis as it may lead to fatal complications.Summary of Papilloedema Papilloedema is a neurological emergency. Responsibility for diagnosis rests with the Ophthalmologist. . When in doubt always err on the right side. Don’t hesitate to do neuro imaging when you are in doubt.