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Important questions in papilloedema ?

Prof. K. Vengala Rao

What causes OD to swell ?

1. Pre laminar axon distension 2. Extra cellular oedema

Why pre laminar axons swell ? .

Blocked axoplasmic flow at laminar gate .

What causes block in axoplasmic flow ? .

Ciliary ischemia .Compression of axons 2.1.

Why is the ON so vulnerable to raised ICP ? .

Ciliary flow to laminar region is weak (Choroidal steal) .

Can you distinguish Ophthalmoscopically papilloedema from other causes of disc oedema ? .

Yes and No Papilloedema is not segmental Papilloedema is not pallid Papilloedema is not mono ocular (usually) It can be asymmetrical Disc is more swollen than NFL .

What gets confused with papilloedema ? .

Congenital OD elevation Acquired causes that look like papilloedema ION Increased BP Increased blood sugar (Papillopathy) Indentation (Orbital mass) Inherited (LHON) Intoxication (Methanol) Infiltration (Cancer) Inflammation (Peri neuritis. Posterior Uveitis) . Sarcoid.

Why does papilloedema look like other causes of acquired oedema ? .

Axoplasmic stasis is common to all causes of disc oedema .

How to distinguish from other causes ? .

Visual function is well preserved Except in acute papilloedema Macular oedema Atrophic papilloedema .

Why is vision relatively preserved in acute papilloedema ? .

Elevated ICP impairs axoplasmic flow less than local causes .

Why does vision fall in chronic papilloedema ? .

Shut down of all axoplasmic flow (slow and fast) Compression of ciliary vessels with infarction .

Can you predict whether vision will fail in papilloedema ? .

Not very well Risk factors for vision failure Systemic Hypertension High ICP Pre – existing optic neuropathy Disc pallor .

Can acute elevated ICP exist with out papilloedema ? .

YES.! Hayreh 30% have papilloedema after 24 hrs 90% have papilloedema after 5 days .

Does papilloedema reflect current ICP elevation ? .

Not necessarily It takes papilloedema a long time to go away after ICP has normalized .

Can chronic elevated ICP exist with out papilloedema ? .

Not very often.! Chronically elevated ICP can produce unilateral (or very asymmetrical) papilloedema Chronic elevated ICP can exist with normal ODs (patients with headache) .

Why might papilloedema not occur in chronic ICP elevation ? .

Pressure rise is slow No communication between intracranial and intra orbital subarachnoid space Atrophic ON .

What is the significance of finding papilloedema ? .

ICP has not been chronically elevated Ventriculomegaly does not mean raised ICP Small ventricle do not mean ICP is normal .ICP is (or was) elevated If you do not find papilloedema.

What is the best surgical treatment for papilloedema ? .

ONSF if there is fall of vision LP shunt or VP shunt if headache is severe There is no comparative study so far .

Thank You… .