Papilledem

Papilledem, commonly referred to as papilledema, is swelling of the optic disc caused by raised intracranial pressure. It is a sign rather than a disease and is typically bilateral, though asymmetry can occur early in some conditions. The edema stems from impaired axoplasmic flow at the optic nerve head and venous congestion within the optic nerve sheath.

Common causes include intracranial mass lesions, hydrocephalus, cerebral venous sinus thrombosis, idiopathic intracranial hypertension (pseudotumor cerebri), intracranial infection or hemorrhage, and severe hypertension. Risk factors for idiopathic intracranial hypertension include obesity and young to middle-aged women.

Clinically, headaches are common and patients may report transient visual obscurations, nausea, vomiting, or pulsatile tinnitus. On examination, the optic discs appear swollen with blurred margins and hyperemia; the retinal vessels may be tortuous, and small hemorrhages or cotton-wool spots can occur. Visual acuity is often preserved early, but there may be an enlarged blind spot and progressive visual field loss if the underlying pressure is not controlled.

Diagnosis relies on a stepwise assessment. Ophthalmologic examination detects disc swelling. Neuroimaging, typically MRI with MR venography, is performed to exclude mass lesions and venous sinus thrombosis. If imaging is unrevealing and signs of intracranial pathology are absent, a lumbar puncture measures opening pressure; opening pressure is typically elevated in papilledema, and cerebrospinal fluid composition is usually normal. Differential diagnoses include optic neuritis or other optic neuropathies without disc edema.

Management focuses on treating the underlying cause. In idiopathic intracranial hypertension, first-line therapy includes acetazolamide, weight reduction, and sometimes topiramate; therapeutic lumbar punctures may provide temporary relief. In vision-threatening cases, surgical options such as optic nerve sheath fenestration or CSF shunting may be considered. Regular ophthalmologic follow-up is essential to monitor vision.