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Clinical Summary

Papilledema involves swelling of the optic nerve head, usually in association with elevated intracranial pressure. The optic disks are hyperemic with blurred disk margins; the venules are dilated and tortuous. The optic cup may be obscured by the swollen disk. There may be flame hemorrhages and infarctions (white, indistinct cotton wool spots) in the nerve fiber layer and edema in the surrounding retina.

FIGURE 3.26

Papilledema. Note blurred disk margins and congested disk. (Photo contributor: Arun D. Singh, MD.)

Ocular inflammation (eg, papillitis), tumors or trauma, central retinal artery or vein occlusion, optic nerve drusen, and marked hyperopia may present with similar findings.

Management and Disposition

Expeditious ophthalmologic and medical evaluation is warranted.

Pearls

  1. The top of a swollen disk and the surrounding unaffected retina will not both be in focus on the same setting on direct ophthalmoscopy.

  2. Papilledema is a bilateral process, although it may be slightly asymmetric. A unilateral swollen disk suggests a localized ocular or orbital process.

  3. Vision is usually normal acutely, although the patient may complain of transient visual changes. The blind spot is usually enlarged.

  4. Diplopia from 6th cranial nerve palsy can be associated with increased intracranial pressure and papilledema.

FIGURE 3.27

Papilledema. Disk is hyperemic and swollen with loss of sharp margins. The venules are dilated and tortuous. The cup is obscured. A small flame hemorrhage is seen at 12- to 1-o’clock position on the disk margin. (Photo contributor: Department of Ophthalmology, Naval Medical Center, Portsmouth, VA.)

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Video 03-01: Spontaneous Venous Pulsations
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