Chapter 107 The swollen optic disc
The diagnosis of the cause of a swollen optic disc is made by history and the accompanying visual and other ocular signs and symptoms, not just by ophthalmoscopy of the disc, even though that plays an important role (Figs 107.1–107.23). Figure 107.1 shows the importance of this and how one presentation can progress to another. For instance, papilledema (disc swelling due to raised intracranial pressure) starts with normal acuity and color vision and slightly enlarged blind spots but can progress to severe visual loss.
Fig. 107.1 The importance of the history and the accompanying visual and other ocular signs and symptoms and how one presentation can progress to another. For instance, papilledema (disc swelling due to raised intracranial pressure) starts with normal acuity and color vision and slightly enlarged blind spots but can progress to severe visual loss. NVM/RH = Neovascular membrane/Retinal Hemorrhage. MNFs = Myelinated Nerve Fibres.
Fig. 107.2 This 10-year-old girl with idiopathic intracranial hypertension (pseudotumor cerebri) had a recurrence of symptoms of headache following cessation of treatment. Both optic discs show slight elevation and indistinct margins due to thickening of the nerve fiber layer around the disc. The lumbar puncture opening pressure was 35 cm of CSF. Visual acuity and color vision were normal. The visual fields showed marginally enlarged blind spots.
Fig. 107.3 This 10-year-old boy presented with 3 weeks of increasing headaches with morning nausea and vomiting and was diagnosed as having an ependymoma of the fourth ventricle. The optic discs are elevated, the veins dilated and tortuous. The disc capillaries are dilated and the nerve fibers around the optic discs are thickened with the result that the reflexes from the internal limiting membrane (ILM, red arrows) are displaced away from their normal position near the disc margin. Visual acuities were 0.0 logMAR (6/6, 20/20, 1.0) and the visual fields showed larger than normal blind spots on Goldmann fields: papilledema due to raised intracranial pressure.
Fig. 107.4 Optic discs of a 6-year-old child with a medulloblastoma who had for a month behaved oddly, lost weight, with illness and vomiting. The optic discs are markedly elevated with dilated capillaries and veins, displaced ILM light reflexes (red arrows), cotton wool spots (blue arrows) which suggest ganglion cell axonal death, and hemorrhages (green arrows). The visual acuity and color vision were normal, but the visual fields showed prominently large blind spots on confrontation testing. The intracranial pressure was markedly raised.
Fig. 107.5 This 7-year-old boy with a brain stem glioma presented with diplopia associated with bilateral sixth nerve palsies (see Chapter 83) that had started gradually about 2 months before and more recent symptoms of raised intracranial pressure. The optic discs are grossly elevated with markedly dilated capillaries and veins, numerous cotton wool spots, and the right eye has a macular star, as a result of protein/lipid accumulation from transudation from disc capillaries. Although the blind spots were very large on Goldmann fields, the visual acuity was 0.1 (6/7.5, 20/25, 0.8) right and 0.0 left.