Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pseudopapilledema Clinical Presentation

  • Author: Mitchell V Gossman, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Oct 06, 2015
 

History

Most patients are asymptomatic. No visual symptoms are usually present.

Visual field loss

In many patients with disc drusen, visual field defects eventually develop along with afferent pupil defect, though patients usually remain symptom free.

Transient visual obscurations

A minority of patients with disc drusen experience transient visual flickering or graying out that is similar to transient visual obscurations that are sometimes seen in patients with papilledema.

Rarely, patients might experience permanent visual loss from secondary processes. For example, disc drusen may increase the risk of later developing subretinal neovascular membranes, retinal vascular occlusion, or ischemic optic neuropathy.

Visual acuity

Patients with disc drusen may eventually lose central acuity. Although unusual, this visual loss would most likely follow a long period of gradual field constriction, otherwise this should arouse suspicion of another process.

Next

Physical

Take a history concentrating on neurologic problems and symptoms, hypertension, and febrile illness.

Perform visual acuity, color vision, and pupillary examinations. If present, document a relative afferent pupillary defect. Although the presence or absence of an afferent pupillary defect is not helpful diagnostically per se, generally, an afferent pupil defect is mild with early field loss.

Blood pressure should be checked since optic nerve swelling can be a sign of malignant hypertension, a treatable systemic medical emergency.

Perform a careful dilated fundus examination.

Edema of the nerve fiber layer that blurs the disc margins and the peripapillary vasculature is a hallmark of true papilledema. Usually, the peripapillary vessels are clearly seen in pseudopapilledema, except in such cases as myelinated nerve fibers.

The angle of the optic nerve head should be noted. A tilted disc results from an optic nerve that enters the eye at a sharply oblique angle; it usually has a characteristic appearance of a prominently elevated nasal aspect with a poorly defined or sunken temporal aspect. Patients with tilted discs may have associated marked astigmatism or high myopia.

Other anatomical variants include persistent hyaloid remnants, gliosis of the optic nerve head, and myelination of the nerve fiber layer. These entities have a characteristic appearance on dilated fundus examination.

When superficial drusen (small, white-to-yellow, granular bulging of the substance of the disc) are present, they greatly aid in the diagnosis. At other times, drusen can be deeply buried in the substance of the nerve, and the clinical diagnosis is more subtle. Buried drusen may be visualized via retroillumination of the peripapillary retina and the sclera. See the image below.

Superficial optic nerve drusen. Note the irregular Superficial optic nerve drusen. Note the irregular disc margins with preserved vascular and perivascular detail.

In papilledema, the disc is usually hyperemic with sometimes subtle dilatation of the superficial optic nerve vessels, and an increased frequency of hemorrhages and cotton-wool spots exists. Also, Paton lines and optociliary shunt vessels may be seen with retention of the central cup until late in the course of the disease. A severely crowded nerve due to other causes (eg, hyperopia, disc drusen) may display subtle congestion of optic nerve vasculature as well.

In pseudopapilledema, the disc is yellow, the cup may be small or absent, venous congestion is not present, spontaneous venous pulsations are often present, congenitally anomalous vessels may be seen, and the disc abnormality may be familial.

It may be fruitful to examine family members for disc drusen.

Previous
Next

Causes

See the list below:

  • Congenitally anomalous disc
  • Hyperopia
  • Optic disc drusen
  • Tilted disc
  • Myelinated nerve fiber layer
Previous
 
 
Contributor Information and Disclosures
Author

Mitchell V Gossman, MD Partner and Vice President, Eye Surgeons and Physicians, PA; Medical Director, Central Minnesota Surgical Center; Clinical Associate Professor, University of Minnesota Medical School

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, 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, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Georgia Chrousos, MD Clinical Professor, Department of Ophthalmology, Division of Neuro-Ophthalmology and Pediatric Ophthalmology Services, Georgetown University Medical Center

Disclosure: Nothing to disclose.

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.

References
  1. Tan DK, Tow SL. Acute visual loss in a patient with optic disc drusen. Clin Ophthalmol. 2013. 7:795-9. [Medline]. [Full Text].

  2. Sato T, Mrejen S, Spaide RF. Multimodal Imaging of Optic Disc Drusen. Am J Ophthalmol. 2013 May 12. [Medline].

  3. Merchant KY, Su D, Park SC, Qayum S, Banik R, Liebmann JM, et al. Enhanced Depth Imaging Optical Coherence Tomography of Optic Nerve Head Drusen. Ophthalmology. 2013 Mar 23. [Medline].

  4. Lee KM, Woo SJ, Hwang JM. Morphologic characteristics of optic nerve head drusen on spectral-domain optical coherence tomography. Am J Ophthalmol. 2013 Jun. 155(6):1139-1147.e1. [Medline].

  5. Grippo TM, Shihadeh WA, Schargus M, Gramer E, Tello C, Liebmann JM, et al. Optic nerve head drusen and visual field loss in normotensive and hypertensive eyes. J Glaucoma. 2008 Mar. 17(2):100-4. [Medline].

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

  7. Auw-Haedrich C, Staubach F, Witschel H. Optic disk drusen. Surv Ophthalmol. 2002 Nov-Dec. 47(6):515-32. [Medline].

  8. Cullom RD, Chang B. The Wills Eye Manual. 1994. 270-272.

  9. Kline LB. Optic Nerve Disorders. 1996. 37-53.

  10. Miller NR, Newman NJ. Clinical Neuro-Ophthalmology - The Essentials. 1999. 166-195.

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

  12. Yanoff M, Duker JS. Ophthalmology. 1999. 11.5.1-5.4.

  13. Asensio-Sánchez VM, Trujillo-Guzmán L. SD-OCT to distinguish papilledema from pseudopapilledema. Arch Soc Esp Oftalmol. 2015 Oct. 90 (10):481-483. [Medline].

 
Previous
Next
 
Superficial optic nerve drusen. Note the irregular disc margins with preserved vascular and perivascular detail.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.