eMedicine Specialties > Ophthalmology > Optic Nerve

Papilledema: Differential Diagnoses & Workup

Author: Mitchell V Gossman, MD, Partner and Vice President, Eye Surgeons and Physicians, St Cloud
Coauthor(s): Joseph Giovannini, MD, Chief of Ophthalmology, Eye Surgery Center, David Grant Medical Center, Travis Air Force Base
Contributor Information and Disclosures

Updated: Dec 17, 2008

Differential Diagnoses

Central Retinal Vein Occlusion
Scleritis
Hypertension
Thyroid Ophthalmopathy
Idiopathic Intracranial Hypertension
Toxic/Nutritional Optic Neuropathy
Optic Neuritis, Adult
Toxoplasmosis
Optic Neuropathy, Anterior Ischemic
Uveitis, Classification
Optic Neuropathy, Compressive
Vogt-Koyanagi-Harada Disease
Pseudopapilledema
Sarcoidosis

Other Problems to Be Considered

Optic disc infiltrates
Other optic nerve tumors
Diabetic papillitis

Workup

Laboratory Studies

  • Blood tests usually do not contribute to the diagnosis of papilledema. If the diagnosis is in doubt, CBC count, blood sugar, angiotensin-converting enzyme, erythrocyte sedimentation rate, and syphilis serology may be helpful to look for signs of infectious, metabolic, or inflammatory diseases.

Imaging Studies

  • Urgent neuroimaging (eg, CT scan, MRI) of the brain with contrast should be performed in an attempt to identify a CNS mass lesion.
  • Consider magnetic resonance (MR) venography to detect venous sinus thrombosis.
  • B-scan ultrasonography may be useful to rule out buried disc drusen.
  • Fluorescein angiography can be used to help establish the diagnosis. Acute papilledema exhibits increased dilation of the peripapillary capillaries with late leakage of the dye. Autofluorescence may reveal disc drusen.

Other Tests

  • Perimetry
    • Visual fields should be tested. They commonly show enlargement of the blind spot. With extreme disc edema, a pseudo–bitemporal hemianopsia may be seen.
    • With chronic papilledema, constriction of the visual field, especially inferiorly, gradually can occur, which eventually may progress to a loss of central acuity and total blindness.
  • Stereo color photographs of the optic discs are useful to document changes.

Procedures

  • A lumbar puncture should be performed following a normal MRI to assess the opening pressure of the CSF and to obtain CSF for analysis to rule out neoplastic and infectious etiologies. It may provide some therapeutic benefit, as the CSF pressure is reduced temporarily.

More on Papilledema

Overview: Papilledema
Differential Diagnoses & Workup: Papilledema
Treatment & Medication: Papilledema
Follow-up: Papilledema
References
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References

  1. Nadkarni T, Rekate HL, Wallace D. Resolution of pseudotumor cerebri after bariatric surgery for related obesity. Case report. J Neurosurg. Nov 2004;101(5):878-80. [Medline].

  2. Acheson JF, Sanders MD. Common Problems in Neuro-ophthalmology. 1997:78-84.

  3. Cullom RD, Chang B. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 2nd ed. Lippincott-Raven: 1994:270-272.

  4. Kline LB. Optic Nerve Disorders, Ophthalmology Monographs. American Academy of Ophthalmology. 1996;37-53.

  5. Mathews MK, Sergott RC, Savino PJ. Pseudotumor cerebri. Curr Opin Ophthalmol. Dec 2003;14(6):364-70. [Medline].

  6. Miller NR, Newman NJ. The Essentials: Walsh & Hoyt's Clinical Neuro-ophthalmology. 5th ed. Lippincott Williams & Wilkins; 1998:166-195.

  7. Vaphiades MS. The disk edema dilemma. Surv Ophthalmol. Mar-Apr 2002;47(2):183-8. [Medline]. [Full Text].

  8. Yanoff M, Duker JS. Ophthalmology. 1999:11.5.1-5.4.

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Further Reading

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Keywords

papilledema, optic nerve sheath, optic nerve head, optic disc swelling, elevated intracranial pressure, acute papilledema, papillitis, pseudotumor

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Contributor Information and Disclosures

Author

Mitchell V Gossman, MD, Partner and Vice President, Eye Surgeons and Physicians, St Cloud
Mitchell V Gossman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Minnesota Medical Association, North American Neuro-Ophthalmology Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Giovannini, MD, Chief of Ophthalmology, Eye Surgery Center, David Grant Medical Center, Travis Air Force Base
Joseph Giovannini, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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