| Identifier |
papilledema_Lee |
| Title |
Papilledema |
| Creator |
Andrew G. Lee, MD; Quiancheng Wang |
| Affiliation |
(AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (QW) Class of 2023, Baylor College of Medicine, Houston, Texas |
| Subject |
Papilledema; Frisen; MRI; Emergency |
| Description |
Summary: Definition: papilledema is edema of the papilla-the head of the optic nerve easily visible when looking into the eye. Severity: Graded on the Friśen scale • Grade one: c-shaped halo of elevation nasally but the temporal border is intact • Grade two: 360 degrees of the elevation • Grade three: obscuration from peripapillary nerve fiber layer obscuration of a major blood vessel as it crosses the margin • Grade four: obscuration of the major vessel in the center • Grade five (only some people use this term): everything is obscured • Important: The Friśen scale is good for monitoring a patient's change over time but may not be indicative of the severity of physiological abnormality or injury underlying the papilledema. Diagnosis • Papilledema is an emergency • Step one: measure the blood pressure. Hypertension is indicative target and organ dysfunction. • Step two: MRI and MRV should be performed to rule out venous thrombosis. • Step three: Lumbar puncture should also be performed to measure opening pressure. • Important: normal CSF but elevated opening pressure is a sign of idiopathic intracranial hypertension (IIH). Treatment: • Outpatient: young, obese female patients who have had prolonged blindness, headache and symptoms by elevated ICP. Or thin elderly or male or who is atypical in any way or has significant vision loss and papilledema. o Idiopathic intracranial hypertension: weight loss is the best long-term treatment of the disorder and acetazolamide Diamox. • Inpatient: papilledema fulminant IH with significant visual loss-surgery needed o Surgery: optic nerve sheath fenestration, a shunting procedure, or venous sinus stenting; Papilledema is always an emergency, but not all patients need be admitted. A CT is always recommended, but the decision for hospitalization can be made after work up of the patient. |
| Transcript |
Today we are we talking about papilledema and as the name implies its edema of the papilla, which is the optic nerve head. The visible part when we look in the eye. When we're looking at papilledema, we want to use a grading scale and the one that's the most popular is called the Friśen or Friśen grading scale and so grade zero is you have nothing. Grade one is a c-shaped halo of elevation nasally, but the temporal border is intact. Once you have grade two, you have 360 degrees of the elevation. So, this is one this is two. Grade three Friśen is when you have obscuration from peripapillary nerve fiber layer obscuration of a major blood vessel as it crosses the margin. So, we have the edema from grade 2 then we have obscuration of the major vessel as it crosses the border. And in grade four we have obscuration of the major vessel in the center. So, some people use a grade five as well which is everything is obscured, so in the Friśen scale we want to know how bad it is. Unfortunately, the Friśen scale doesn't correlate with actual stage and doesn't take into account hemorrhages and exudates and subretinal fluid so we don't use it to differentiate true papilledema from pseudo papilledema but it's useful for grading patients as you're watching them over time, especially patients with increased intracranial pressure from pseudotumor cerebri the idiopathic variety. Papilledema is an emergency because we want to make sure that it's not things that need to be treated today, and the first thing we need to do in every patient who has papilledema is check the blood pressure, because if we have papilledema from elevated blood pressure that is evidence of target and organ dysfunction and is grade four in the Keith Wagner classification of hypertensive retinopathy. So, grade four hypertensive retinopathy is papilledema but any Friśen grade of papilledema actually qualifies for grade four hypertensive retinopathy and grade four hypertensive retinopathy can mimic what looks like papilledema. The second thing we need to do is we need to do an imaging study and the imaging study of choice for papilledema is a contrast MRI of the head and orbit with MRVenography. The venography is necessary to look for venous sinus thrombosis and then if the MRI, MRV is normal then of course we're going to do a lumbar puncture to measure the opening pressure. And if the CSF content is normal but the opening pressure is elevated that meets the modified Dandy criteria for idiopathic intracranial hypertension (IIH). However, some patients with papilledema come to you months after they've had symptoms and that you do the visual field and it's just an enlarged blind spot; they've had headache and symptoms by elevated ICP; they're an obese female so those patients I don't think have to have any admission to the hospital and can be worked up as an outpatient. But anybody who's thin elderly or male or who is atypical in any way, or has significant vision loss and papilledema probably should have a CT scan and on an emergent basis in addition to checking their blood pressure and then you can schedule them for the MRI MRV and the lumbar puncture as outpatient. If it is idiopathic intracranial hypertension, weight loss is the best long-term treatment of the disorder and acetazolamide Diamox was shown in a clinical trial to be superior so we would start acetazolamide Diamox if there's no contraindication. For patients who have papilledema, who have vision loss but if it's acute and fulminant, they have loss of acuity or they have severe visual loss that we would admit to the hospital even though you're going to start medical therapy. You're still going to do the blood pressure, you're still going to do the MRI MRV, you're still going to do the lumbar puncture, but in those patients, who have fulminant IH with significant visual loss we're going to do surgery on those people. And your choices are optic nerve sheath fenestration, a shunting procedure, or venous sinus stenting. It probably doesn't matter which one of those you choose that's surgeon and institution dependent but probably you're going to have to do some sort of surgical procedure on acute fulminant IH even though you're treating it with medical therapy. So, in summary papilledema of any grade should be evaluated urgently. It's an emergency if it's hypertensive emergency. It's an emergency if we see a tumor or if we have venous sinus thrombosis. It's an emergency if the lumbar puncture shows meningitis, if the patient is pregnant, immunocompromised you should admit those patients, however if it's an obese young female who's had symptoms for a long time and it's not fulminant IH I think you probably can get by with that outpatient evaluation in this setting. However, doing a CT scan to rule out intracranial mass lesion if there's anything atypical about it is probably a reasonable plan. |
| Date |
2019-10 |
| Language |
eng |
| Format |
video/mp4 |
| Type |
Image/MovingImage |
| Collection |
Neuro-Ophthalmology Virtual Education Library: Andrew G. Lee Collection: https://novel.utah.edu/Lee/ |
| Publisher |
North American Neuro-Ophthalmology Society |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Rights Management |
Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s6zw6bfd |
| Setname |
ehsl_novel_lee |
| ID |
1469315 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s6zw6bfd |
