Papilledema

Case Report: Atypical visual presentation caused by a large convexity meningioma-a nerve stretching and stalk indentation effect

Visual field defects are commonly present in patients with brain tumors, particularly due to direct compression on the optic apparatus. However, there are instances where brain tumors, despite not directly compressing the optic pathway, can still cause visual symptoms, albeit rarely reported but not uncommonly observed. These mechanisms are thought to be associated with increased intracranial pressure (IICP). We report a case of a 32-year-old man who presented with right blurred vision and was diagnosed with a right convexity meningioma. Upon reviewing his magnetic resonance images, we hypothesized that the indentation of the pituitary stalk on the optic chiasm and the stretching of the optic nerve, combined with a focal effect of IICP, could be responsible for his atypical visual field defect.

The Relationship between Lumbar Puncture Opening Pressure and Retinal Nerve Fiber Layer Thickness in the Diagnosis of Idiopathic Intracranial Hypertension: Is a Lumbar Puncture Always Necessary?

OBJECTIVES

Idiopathic intracranial hypertension (IIH), is characterized by elevated intracranial pressure (ICP) without an identified cause. Today, lumbar puncture (LP) is the most common method used for diagnosis by measuring cerebrospinal fluid (CSF) pressure to reflect intracranial pressure. This invasive examination has significant disadvantages, such as complications and negative experiences for patients. Therefore, noninvasive methods for ICP measurement are desired. Optical coherence tomography (OCT) is widely used for the diagnosis and follow-up of IIH patients as it reflects papilledema. The aim of this study is to investigate the relationship between CSF pressure and OCT parameters and the ability of OCT in the diagnostic approach.

METHODS

In our study, patients who were followed up with a diagnosis of IIH with complete neuro-ophthalmological examinations, including visual acuity (VA), visual field, and OCT imaging within 24 hours before lumbar puncture, were retrospectively evaluated. CSF pressure, visual acuity LogMAR, mean deviation of visual fields, retinal nerve fiber layer (RNFL) thickness measured by OCT, and treatment protocols were obtained from our hospital data system.

RESULTS

A total of 42 eyes of 21 patients were enrolled in the study. A statistically significant positive and moderate correlation was found between CSF pressure values and average RNFL thickness ( r =0.507; P =0.001). The same relationship was demonstrated in all 4 quadrants: inferior, superior, nasal, and temporal.

CONCLUSIONS

Increased peripapillary RNFL thickness in optic nerve head OCT may be correlated with increased ICP in IIH patients. A larger number of patients are needed to better understand the correlation between OCT parameters and CSF pressure in patients with IIH.

Neuro-ophthalmology Emergency Department and Inpatient Consultations at a Large Academic Referral Center

PURPOSE

Prompt neuro-ophthalmology consultation prevents diagnostic errors and improves patient outcomes. The scarcity of neuro-ophthalmologists means that the increasing outpatient demand cannot be met, prompting many emergency department (ED) referrals by non-neuro-ophthalmologists. We describe our quaternary care institution's ED and inpatient neuro-ophthalmology consultation patterns and patient outcomes.

DESIGN

Prospective observational study.

PARTICIPANTS

Consecutive neuro-ophthalmology ED and inpatient consultation requests over 1 year.

METHODS

We collected patient demographics, distance traveled, insurance status, referring provider details, consultation question, final diagnosis, complexity of consultation, time of consultation, and need for outpatient follow-up.

MAIN OUTCOME MEASURES

Consultation patterns and diagnoses, complexity, and follow-up.

RESULTS

Of 494 consecutive adult ED and inpatient neuro-ophthalmology consultations requested over 1 year, 241 of 494 consultations (49%) occurred at night or during weekends. Of ED consultations (322 of 494 [65%]), 127 of 322 consultations (39%) occurred during weekdays, 126 of 322 consultations (39%) occurred on weeknights, and 69 of 322 consultations (22%) occurred on weekends or holidays. Of 322 ED consultations, 225 of 322 consultations (70%) were patients who initially sought treatment in the ED with a neuro-ophthalmic chief symptom. Of the 196 patients sent to the ED by a health care professional, 148 patients (148/196 [76%]) were referred by eye care specialists (74 optometrists and 74 ophthalmologists). The most common ED referral questions were for papilledema (75 of 322 [23%]) and vision loss (72 of 322 [22%]). A total of 219 of 322 patients (68%) received a final active neuro-ophthalmic diagnosis, 222 of 322 patients (69%) were cases of high or very high complexity, and 143 of 322 patients (44%) required admission. Inpatient consultations (n = 172) were requested most frequently by hospitalists, including neurologists (71 of 172 [41%]) and oncologists (20 of 172 [12%]) for vision loss (43 of 172 [25%]) and eye movement disorders (36 of 172 [21%]) and by neurosurgeons (58 of 172 [33%]) for examination for mass or a preoperative evaluation (19 of 172 [11%]). An active neuro-ophthalmic diagnosis was confirmed in 67% of patients (116 of 172). Outpatient neuro-ophthalmology follow-up was required for 291 of 494 patients (59%).

CONCLUSIONS

Neuro-ophthalmology consultations are critical to the diagnosis and management in the hospital setting. In the face of a critical shortage of neuro-ophthalmologists, this study highlights the need for technological and diagnostic aids for greater outpatient access.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Optic nerve sheath fenestration: A second lease at sight

Purpose

To study the safety and efficacy of optic nerve sheath fenestration surgery in patients with optic disc edema due to different etiologies.

Methods

Records of 18 eyes of 15 patients who underwent optic nerve sheath fenestration for vision threatening optic disc edema were reviewed retrospectively, and results were analyzed. Improvement of visual acuity was the main measure of outcome. Improved visual fields, resolution of optic disc edema, diplopia, and headache were other benefits that were observed.

Results

Fifteen patients between 13 and 54 years of age were included in the study. Three patients underwent successive bilateral surgery. Idiopathic intracranial hypertension was the most common cause for optic disc edema and was found in 80% of the patients. Mean preoperative logMAR acuity was -1.9789 ± 1.46270, which improved to -0.9022 ± 1.23181 (p < 0.005) in the operated eye, and mean logMAR acuity of contralateral eye improved from -1.3378 ± 1.50107 to -1.0667 ± 1.33813 (p < 0.05).

Conclusion

Early optic nerve sheath fenestration is an effective modality for treating optic disc edema due to a wide myriad of causes and helps resolve the associated symptoms.

Papilledema and Anemia: A Rare Association

Papilledema is the swelling of the optic disc due to the transmission of intracranial pressure through the optic nerve. It can occur as a symptom of various intracranial pathologies that elevate the intracranial pressure. Even though anemia has been described as an association with raised intracranial pressure, the exact causal relationship between the two has not been well established in the literature. We present one such unusual case wherein a 21-year-old female patient, who complained of headaches, was found to have papilledema and severe anemia. After an unyielding workup for secondary causes, the rare association between papilledema and anemia was considered and prompt hemoglobin correction was ensued. Subsequently, resolution of papilledema and improvement in the visual acuity of the patient was observed. Although the causal relationship between anemia and papilledema has not been thoroughly explained, appropriate workup and correction of anemia play an integral role in the management of patients with papilledema and the prevention of long-term ocular complications.

Thickened Retinal Nerve Fiber Layers Associated With High-Altitude Headache

Purpose: This study aimed to quantify the different quadrants of the optic nerve head (ONH) and macular parameters and their changes during exposure to high altitude, and to assess their correlation with high-altitude headache (HAH).

Methods: Spectral-domain optical coherence tomography (OCT) was used to quantify changes in the retinal structure in 109 healthy subjects during acute exposure to high altitude (3,700 m). Self-reported symptoms of HAH and acute mountain sickness AMS were assessed using Lake Louise Score (LLS), alongside measurements of physiological parameters (oxygen saturation [SpO2], heart rate [HR], hemoglobin level [Hb], and red blood cell [RBC] count). Measurements were taken before and after exposure to the high-altitude environment. The correlations of these parameters and changes at ONH were examined.

Results: With the exposure to high altitude, the incidence of AMS was 44.0% and the frequency of HAH was 67.0% (54.1% mild, 12.9% moderate-severe). As for systemic parameters measured at high altitude, the participants exhibited significantly lower SpO2, higher resting HR, higher Hb, and a higher RBC (all p &lt; 0.05). Key stereometric parameters used to describe ONH [superior, inferior, nasal, temporal, and mean retinal nerve fiber layer (RNFL) thickness] and macula (macular thickness) increased at high altitude compared with baseline. Most parameters of ONH changed, especially superior, inferior, and mean RNFL thickness (p &lt; 0.05). There was a significant correlation between the ratios of RNFL at ONH and HAH [mean thickness (r = 0.246, p = 0.01); inferior (r = 0.216, p = 0.02); nasal (r = 0.193, p = 0.04)]. No associations between parameters of ONH and AMS or LLS were observed.

Conclusion: The high-altitude environment can increase RNFL thickness at ONH. Furthermore, we found that the ratios of mean thickness, inferior area, and nasal area correlated positively with HAH, which provides new insights for understanding of the underlying pathological mechanisms of high-altitude retinopathy (HAR).

Trends and Clinical Characteristics of Pediatric Patients Presenting to an Ophthalmology Emergency Department with an Initial Diagnosis of Optic Nerve Head Elevation

Objective

Optic nerve head elevation may be the only clinical sign of a vision- and/or life-threatening condition, particularly in children who are asymptomatic or fail to report symptoms. The purpose of this study is to identify epidemiologic trends, clinical characteristics, and diagnostic outcomes of pediatric patients presenting to an ophthalmology emergency department (ED) with suspected optic nerve head elevation.

Methods

This retrospective study identified pediatric patients (≤18 years) presenting to an ophthalmology ED over a five- year period with suspected optic nerve head elevation to describe demographic trends, clinical characteristics, and diagnostic outcomes.

Results

Of the 213 patients, the majority were female (73.2%) and tended to be older than males (14.3 vs 11.2 years, p<0.001). The most common diagnoses were papilledema (52.6%), pseudopapilledema (31.5%), and optic nerve drusen (8.0%). When symptoms were present, most (73.7%) patients presented with headache (67.5%) or visual disturbance (54.8%). Of 144 neuroimaging studies obtained, 80 (55.6%) had positive findings and these were significantly associated with symptoms at presentation (p=0.017) and age (p=0.034), but not sex (p=0.791). Asymptomatic females and children >12 years old were more likely to have an abnormal MRI than males and children ≤ 12 (OR=1.56 and 1.22, respectively).

Conclusion

Patient demographics such as age and sex in conjunction with concurrent symptoms are important factors in determining the urgency of neuroimaging in children with suspected optic nerve head elevation.

Clinical and Multi-Mode Imaging Features of Eyes With Peripapillary Hyperreflective Ovoid Mass-Like Structures

Purpose

To observe and analyze the clinical and multi-mode imaging features of eyes with PHOMS, and to introduce two cases of PHOMS which underwent multi-mode imaging.

Methods

Retrospective clinical observational study. A total of 26 patients (37 eyes) with hyperreflective structures surrounded by hyporeflective edges around the optic discs who were examined and diagnosed at Shandong Eye Hospital between January 2019 and June 2021 were included in the study. Among these patients, 12 were male and 14 were female. Fifteen were monocular. The average age was 39 years. All patients underwent the following examinations: Best-corrected visual acuity (BCVA), intraocular pressure examinations, slit-lamp anterior segment examinations, indirect ophthalmoscopy, visual field examinations, fundus color photography, fundus autofluorescence (FAF), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA). Some of the patients were examined with fundus fluorescein angiography (FFA). Clinical data and imaging characteristics from the OCT, OCTA, and FFA were analyzed retrospectively.

Results

We found the hyperreflective structures surrounded by hyporeflective edges around the optic discs in 37 eyes. EDI-OCT results revealed hyperreflective structures surrounded by hyporeflective edges around the optic discs in all eyes. Typical hyperreflexia lesions occurred around the optic disc, located subretinally and above Bruch's membrane. OCTA revealed that the highly reflective perioptic material also had vascular structures.

Conclusion

EDI-OCT of PHOMS showed hyperreflective structures surrounded by hyporeflective edges around all of the optic discs. Infra-red photography showed temporal hyperreflexia. These characteristics can be seen in a variety of diseases and may be a relatively common feature revealed by EDI-OCT scanning. These characteristics may also be seen in elderly patients as well as children. PHOMS may be found in optic disc drusen (ODD), tilted disc syndrome (TDS), optic neuritis, ischemic optic neuropathy, and in white dot syndromes. Few patients may be developed into macular neovascularization (MNV). In order to improve the accuracy and robustness of the conclusions and provide better clinical guidance, we need to conduct more comprehensive research in the subsequent clinical work.

Papilledema: A review of etiology, pathophysiology, diagnosis, and management

Papilledema is optic nerve head edema secondary to raised intracranial pressure (ICP). It is distinct from other causes of optic disk edema in that visual function is usually normal in the acute phase. Papilledema is caused by transmission of elevated ICP to the subarachnoid space surrounding the optic nerve that hinders axoplasmic transport within ganglion cell axons. There is ongoing controversy as to whether axoplasmic flow stasis is produced by physical compression of axons or microvascular ischemia. The most common cause of papilledema, especially in patients under the age of 50, is idiopathic intracranial hypertension (IIH); however, conditions that decrease cerebrospinal fluid (CSF) outflow by either causing CSF derangements or mechanically blocking CSF outflow channels, and rarely conditions that increase CSF production, can be the culprit. When papilledema is suspected clinically, blood pressure should be measured, and pseudopapilledema should be ruled out. Magnetic resonance imaging of the brain and orbits with venography sequences is the preferred neuroimaging modality that should be performed next to look for indirect imaging signs of increased ICP and to rule out nonidiopathic causes. Lumbar puncture with measurement of opening pressure and evaluation of CSF composition should then be performed. In patients not in a typical demographic group for IIH, further investigations should be conducted to assess for underlying causes of increased ICP. Magnetic resonance imaging of the neck and spine, magnetic resonance angiography of the brain, computed tomography of the chest, complete blood count, and creatinine testing should be able to identify most secondary causes of intracranial hypertension. Treatment for patients with papilledema should be targeted toward the underlying etiology. Most patients with IIH respond to weight loss and oral acetazolamide. For patients with decreased central acuity and constricted visual fields at presentation, as well as patients who do not respond to treatment with acetazolamide, surgical treatments should be considered, with ventriculoperitoneal shunting being the typical procedure of choice.

Ocular Point-of-Care Ultrasound: Description of Intermediate Uveitis in an Adolescent Female

ABSTRACT

Ocular point-of-care ultrasound has been used to assess for intraocular pathology, including retinal and vitreous detachment. We describe a pediatric patient whose initial point-of-care ultrasound examination appeared to be consistent with bilateral posterior vitreous detachment but who was ultimately diagnosed with intermediate uveitis.

Incidental idiopathic intracranial hypertension

Objective: Idiopathic intracranial hypertension (IIH) is a neuro-ophthalmological syndrome of unknown cause that can be vision-threatening, so an early diagnosis is crucial.

Case report: We reported a case of a 68-year-old asymptomatic male referred with a cataract in his right eye (OD). Best-corrected visual acuity (BCVA) was 70 letters (20/ 40) in the OD and 85 letters (20/ 20) in the left eye (OS). Ophthalmological examination revealed a significant nuclear cataract in the OD that explained the visual acuity. Fundus imaging showed a faint nasal margin elevation of the optic disc of both eyes (OU). Optical coherence tomography (OCT) revealed a sectorial retinal nerve fiber layer (RNFL) atrophy in the inferior quadrant in the OS. Nevertheless, visual field (VF) did not demonstrate defects. Neuroimaging was normal and examination of CSF revealed an opening pressure of 500 mmH2O. A diagnosis of IIH was confirmed and acetazolamide 250 mg twice daily was recommended. After 12 months of follow-up, RNFL thickness remained stable and VF did not confirm defects.

Conclusion: A routine eye examination was the onset of IIH in our case. Thus, the ophthalmologist played a crucial role in the early diagnosis of this syndrome. Papilledema is usually a key criterion for IIH, so after its detection, exclusion diagnosis and treatment should be initiated in order to avoid permanent visual loss.

Optic nerve sheath fenestration in leukemic patients having increased intracranial pressure: a prospective clinical trial

PURPOSE

This study aimed to assess the safety and efficacy of optic nerve sheath fenestration (ONSF) in leukemic children having increased intracranial pressure with severe uncontrolled visual loss on medical treatment and not eligible for venous sinus stenting.

METHODS

In this non-randomized clinical trial, we included patients presenting with severe sight-threatening papilledema due to increased intracranial pressure following leukemia treatment. All included patients were subjected to a complete history taking, assessment of the visual acuity and fundus examination with fundus photography and grading of papilledema using Frisen scale. Patients were evaluated at 2 weeks and 3 months postoperative by recording the best-corrected visual acuity, assessment of the pupillary reaction and fundus examination and fundus photography with grading of papilledema.

RESULTS

Among 20 patients included in this study, there was a statistically significant improvement in visual acuity of both eyes in all patients. The mean postoperative visual acuity was 0.28 ± 0.10 two weeks after surgery in the right eye and it was 0.42 ± 0.16 in the left eye. The mean visual acuity in the right eye three months after surgery was 0.78 ± 0.19 and it was 0.87 ± 0.17 in the left eye. Three months postoperatively, papilledema resolved completely in both eyes. There were no recorded ocular complications.

CONCLUSION

In this study, ONSF was sight-saving procedure in all leukemic patients with a significant improvement in the visual acuity, stabilization of the visual function and resolving of the papilledema over follow-up period. There were no recorded intraoperative or postoperative complications. Further well-designed studies are needed to assert upon these results.

Inpatient Ophthalmology Consultations

Comprehensive patient care requires an integrated approach that often includes different specialties. Of these specialties, Ophthalmology stands out with its variable pathologic conditions, unique tools, and special examination techniques, which are not part of the standard training of internal medicine or other specialties. The authors review prior studies focused on inpatient ophthalmology consultations, common reasons for inpatient ophthalmology consultation, and the recommended approach to the most common ocular complaints that could present to the inpatient provider. They also shed light on the basic ocular history and eye examination that should be obtained before requesting an ophthalmic evaluation.

Etiology of Papilledema in Patients in the Eye Clinic Setting

IMPORTANCE

The study of health conditions associated with papilledema will augment the clinical judgment of eye care professionals treating patients with optic disc edema in determining the urgency of additional evaluation and counseling patients accordingly.

OBJECTIVES

To determine the incidence, demographic characteristics, and etiologies of papilledema based on a unique records-linkage research platform; and to describe the demographic and clinical differences between patients with idiopathic intracranial hypertension (IIH) and other causes of papilledema.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective population-based cross-sectional study of patients treated for papilledema at outpatient eye clinics in Olmsted County, Minnesota, using the Rochester Epidemiology Project. Data were collected from January 1990 to December 2014 and analyzed from September 2018 to April 2019.

MAIN OUTCOMES AND MEASURES

Etiologies of papilledema, body mass index, incidence of headache, or localizing neurologic signs.

RESULTS

Eighty-six patients were diagnosed with papilledema during the 24-year period, providing an age- and sex-adjusted incidence of 2.5 individuals per 100 000 per year; 68 patients (79%) were women, 73 (85%) were white patients, and the median (range) age was 27.7 (6.2-64.2) years. Nineteen patients (22%) presented with a previously diagnosed attributable cause (eg, trauma or intracranial tumor). Among patients presenting with papilledema without a previously diagnosed attributable cause, 58 patients (87%) had IIH, and 9 patients (13%) were found to have a secondary cause of raised intracranial pressure, such as intracranial tumor, cerebral venous sinus thrombosis, or granulomatous meningitis. Patients with IIH had a higher median (range) body mass index (37.5 [20.4-55.7] vs 27.4 [16.6-40.1]; P = .003) and headache prevalence (54 of 58 patients [93%] vs 6 of 9 patients [67%]; P = .004) than patients with other causes of papilledema. Of 9 patients with papilledema but no IIH, 2 (22%) had localizing neurologic signs, such as gait abnormalities, hearing loss, focal weakness or numbness, visual field defects, or aphasia. Among 42 patients with demographic characteristics typically associated with IIH (female sex, with obesity, aged 15 to 45 years, and absent localizing neurologic signs or symptoms), 40 (95%) had papilledema that was associated with IIH. Conversely, among the 19 patients without these demographic characteristics, 7 (37%) had an alternative cause.

CONCLUSIONS AND RELEVANCE

In this study, most patients who presented to the eye clinic with papilledema without a previously known cause were found to have IIH. These patients were more likely to present with headaches and had statistically higher body mass index. Clinicians should take these findings into account when determining the pretest probability of a patient having IIH or an alternative cause of papilledema.