Unusual causes of papilledema: Two illustrative cases

Bilateral Papilledema and Right Esotropia as an Initial Presentation of Acute Myeloid Leukemia in a Young Girl

Leukemia is a malignant hematologic neoplastic disease in which acquired mutations and genetic abnormalities in early hematopoietic precursors cause rapid proliferation of white blood cells (WBC). Acute myeloid leukemia (AML), a subtype of leukemia, is a rare form of cancer that typically manifests in adulthood. Symptoms typically arise due to abnormal proliferation of WBC. Ocular manifestations of such malignancies are rare and they occur more commonly in acute lymphoblastic leukemia (ALL) rather than AML. Furthermore, ophthalmic involvement usually is either a sign of central nervous system involvement or disease relapse. In this article, we report the case of a 14-year-old girl who presented initially with double vision and right eye squint. The patient was later diagnosed with AML with leptomeningeal involvement.

Optic disc edema in fibrous dysplasia/McCune-Albright syndrome: Prevalence, etiologies, and clinical implications

BACKGROUND

Fibrous dysplasia (FD) is a rare disorder of expansile fibro-osseous lesions that may be associated with extraskeletal features as part of McCune-Albright syndrome (MAS). Optic disc edema is a potentially serious ophthalmologic finding that has been rarely reported in patients with FD/MAS. The purpose of this study was to investigate the prevalence and potential clinical associations of optic disc edema in a large cohort.

METHODS

Clinical records were reviewed from subjects in an ongoing FD/MAS natural history study. Computed Tomography scans were evaluated for the presence of structural craniofacial abnormalities associated with optic disc edema, including Chiari I malformation and space-occupying lesions. Craniomorphometric analyses were performed to determine optic canal diameter and intracranial volume. Statistical analyses were performed to compare clinical and radiographic features between subjects with and without optic disc edema.

RESULTS

Optic disc edema was diagnosed in 7/187 subjects, for a prevalence of 3.7%. All subjects with optic disc edema were diagnosed before age 18 years and had mild, non-progressive disease. Radiographic structural abnormalities, including Chiari I malformation, aneurysmal bone cysts, and arachnoid cysts, were associated with higher odds of optic disc edema (odds ratio [OR] 24.3; 95% confidence interval [CI], 4.2 to 121.4; p < 0.01) (OR 18.0; 95% CI, 3.4 to 108.2; p < 0.01). Treatment with leuprolide, a gonadotropin releasing hormone analog, was also associated with optic disc edema (OR 26.0; 95% CI 3.3 to 177.5; p < 0.05). There was no significant association of optic disc edema with other MAS endocrinopathies, medications, optic canal diameter, or intracranial volume.

CONCLUSION

Optic disc edema is an uncommon but potentially serious complication of craniofacial FD, which may occur more frequently in pediatric patients and those with structural craniofacial abnormalities. The potential association of leuprolide therapy with optic disc edema in this population warrants further study.

Megaloblastic anemia and bilateral disc edema: An enigma… Have we figured it out yet?

A 28-year-old male presented with insidious-onset, painless, progressive diminution of vision in both eyes. He denied any other ocular symptoms. On examination, visual acuity in both eyes was 6/60. Color vision and contrast sensitivity were maintained in both eyes. Direct ophthalmoscopy revealed that the optic discs were bilaterally hyperemic and congested, with blurring of all the disc margins and loss of spontaneous venous pulsations. Besides this bilateral disc edema, rest of the clinical examination was normal. Primary intensive search for any intracranial space-occupying lesions returned negative on computed tomography scan imaging. Blood investigations revealed a hemoglobin level of 9.2 g/dl, leukocyte count of 7000 cells/mm³, and serum Vitamin B12 level of 155 pg/ml (200–835 pg/ml). Serum homocysteine and methylmalonic acid levels were done and were found to be elevated. After 4 weeks, visual acuity improved to 6/6 in both the eyes, and laboratory investigations showed no signs of Vitamin B12 deficiency. Nonsurgical causes for papilledema should be considered in the differential diagnosis. Early diagnosis and prompt treatment is the key to a good prognosis in Vitamin B12-deficient optic neuropathy, which has shown to have a good prognosis if treatment is initiated in the first few months after the onset of symptoms.

Fully automated diagnosis of papilledema through robust extraction of vascular patterns and ocular pathology from fundus photographs

Rapid development in the field of ophthalmology has increased the demand of computer aided diagnosis of various eye diseases. Papilledema is an eye disease in which the optic disc of the eye is swelled due to an increase in intracranial pressure. This increased pressure can cause severe encephalic complications like abscess, tumors, meningitis or encephalitis, which may lead to a patient's death. Although there have been several papilledema case studies reported from a medical point of view, only a few researchers have presented automated algorithms for this problem. This paper presents a novel computer aided system which aims to automatically detect papilledema from fundus images. Firstly, the fundus images are preprocessed by going through optic disc detection and vessel segmentation. After preprocessing, a total of 26 different features are extracted to capture possible changes in the optic disc due to papilledema. These features are further divided into four categories based upon their color, textural, vascular and disc margin obscuration properties. The best features are then selected and combined to form a feature matrix that is used to distinguish between normal images and images with papilledema using the supervised support vector machine (SVM) classifier. The proposed method is tested on 160 fundus images obtained from two different data sets i.e. structured analysis of retina (STARE), which is a publicly available data set, and our local data set that has been acquired from the Armed Forces Institute of Ophthalmology (AFIO). The STARE data set contained 90 and our local data set contained 70 fundus images respectively. These annotations have been performed with the help of two ophthalmologists. We report detection accuracies of 95.6% for STARE, 87.4% for the local data set, and 85.9% for the combined STARE and local data sets. The proposed system is fast and robust in detecting papilledema from fundus images with promising results. This will aid physicians in clinical assessment of fundus images. It will not take away the role of physicians, but will rather help them in the time consuming process of screening fundus images.