Medical Care

Therapy, whether medical or surgical, is tailored to the underlying pathological process and the progression of the ocular findings.^{[1, 4]}

Specific therapy should be directed to the underlying mass lesion if present.

Patients should sleep with the head of the bed elevated. Sleep apnea, if present, should be treated.

Diuretics: The carbonic anhydrase inhibitor, acetazolamide (Diamox), may be useful in selected cases, especially cases of idiopathic intracranial hypertension. (In the presence of venous sinus thrombosis, diuretics are a relative contraindication. In this scenario, evaluation by a hematologist is recommended.)

Weight reduction is recommended in cases of idiopathic intracranial hypertension and can be curative.^{[4, 10]} Bariatric surgery may be considered in cases refractory to conventional methods of weight loss.^[11]

Corticosteroids may be effective in cases associated with inflammatory disorders (eg, sarcoidosis).

Consider withdrawing causative medications, as weighed against other medical necessities and alternatives.

Surgical Care

The underlying mass lesion, if present, should be removed.

Lumboperitoneal shunt or ventriculoperitoneal shunt can be used to bypass CSF.

Optic nerve sheath decompression can be used to relieve worsening ocular symptoms in cases of medically uncontrolled idiopathic intracranial hypertension. This procedure probably will not ameliorate persistent headaches if present.

Consultations

Besides an ophthalmologist, a neurologist should be involved in monitoring the patient, and a neurosurgeon may be needed to help evaluate any underlying mass or to perform a shunting procedure.

Diet

Dietary restrictions and consultation with a dietitian in case of idiopathic intracranial hypertension is recommended.

Long-Term Monitoring

The patient should be examined weekly until stabilization of the ocular findings occurs. Well-developed papilledema takes 6-10 weeks to regress, following lowering of intracranial pressure.

Medication

Xie JS, Donaldson L, Margolin E. Papilledema: A review of etiology, pathophysiology, diagnosis, and management. Surv Ophthalmol. 2022 Jul-Aug. 67 (4):1135-1159. [QxMD MEDLINE Link].
Ehlers JP, Shah CP, eds. Papilledema. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2008. 252-254.
Miller NR, Newman NJ, et al, eds. Walsh & Hoyt's Clinical Neuro-ophthalmology: The Essentials. 2nd ed. Lippincott Williams & Wilkins; 2008. 122-145.
Dhoot R, Margolin E. Papilledema. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Sinclair AJ, Burdon MA, Nightingale PG, Matthews TD, Jacks A, Lawden M, et al. Rating papilloedema: an evaluation of the Frisén classification in idiopathic intracranial hypertension. J Neurol. 2012 Jan 12. [QxMD MEDLINE Link].
Scott CJ, Kardon RH, Lee AG, Frisén L, Wall M. Diagnosis and grading of papilledema in patients with raised intracranial pressure using optical coherence tomography vs clinical expert assessment using a clinical staging scale. Arch Ophthalmol. 2010 Jun. 128(6):705-11. [QxMD MEDLINE Link].
Frisén L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry. 1982 Jan. 45 (1):13-8. [QxMD MEDLINE Link].
Mathews MK, Sergott RC, Savino PJ. Pseudotumor cerebri. Curr Opin Ophthalmol. 2003 Dec. 14(6):364-70. [QxMD MEDLINE Link].
Scott CJ, Kardon RH, Lee AG, Frisén L, Wall M. Diagnosis and grading of papilledema in patients with raised intracranial pressure using optical coherence tomography vs clinical expert assessment using a clinical staging scale. Arch Ophthalmol. 2010 Jun. 128 (6):705-11. [QxMD MEDLINE Link].
Faz G, Butler IJ, Koenig MK. Incidence of papilledema and obesity in children diagnosed with idiopathic 'benign' intracranial hypertension: case series and review. J Child Neurol. 2010 Nov. 25(11):1389-92. [QxMD MEDLINE Link]. [Full Text].
Nadkarni T, Rekate HL, Wallace D. Resolution of pseudotumor cerebri after bariatric surgery for related obesity. Case report. J Neurosurg. 2004 Nov. 101(5):878-80. [QxMD MEDLINE Link].
Vaphiades MS. The disk edema dilemma. Surv Ophthalmol. 2002 Mar-Apr. 47(2):183-8. [QxMD MEDLINE Link].
Acheson JF, Sanders MD. Common Problems in Neuro-ophthalmology. 1997. 78-84.
Kline LB. Optic Nerve Disorders, Ophthalmology Monographs. American Academy of Ophthalmology. 1996. 37-53.
Yanoff M, Duker JS. Ophthalmology. 1999. 11.5.1-5.4.
Kovarik JJ, Doshi PN, Collinge JE, Plager DA. Outcome of pediatric patients referred for papilledema. J AAPOS. 2015 Aug. 19 (4):344-8. [QxMD MEDLINE Link].

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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

Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC Professor, Department of Ophthalmology and Vision Sciences, Sunnybrook Hospital, University of Toronto Faculty of Medicine; Incoming Chair of Ophthalmology, University of Alberta Faculty of Medicine and Dentistry, Canada

Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, 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, Canadian Medical Association, Canadian Ophthalmological Society, Canadian Society of Oculoplastic Surgery, Chinese Canadian Medical Society, European Society of Ophthalmic Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Statistical Society of Canada

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.