 And I can't cover everything, but I'm going to try to give you kind of the basics. I'm going to talk about what types of disc findings we can tend to be infuse for pamphlet women. Anybody who's rotated through neuroanthropology knows that that's a big problem. We want to talk about the features of true pamphlet dema, test you in order to evaluate pamphlet dema or work it up, talk about a differential diagnosis, and then possible treatments. So I'm kind of going to go stepwise through this lecture. And the first one is we have to do a history, of course, right? And the kinds of things that you're going to be looking for are to look for things like headache, visual blurring, noises in the head, changes in the vision, et cetera. Know all the how to do the history. So I'm going to take you after the history when you're doing the examination, and that's what we're going to concentrate on today. So the step one is, the question is, is it really swollen? Step two is going to be one eye or two eyes. Step three is making sure you know what the visual exam shows, the visual acuity, looking for an eye in the field and color vision, et cetera. And then trying to determine whether this is true swelling or pseudo swelling, and then work it up for the appropriate condition. So this is an 87-year-old woman. She was referred emergently for patholema. And the cases that I'm going to show you are actual cases that came into our clinic. She had an occasional headache, but she wasn't suffering from any new headaches. She had no changes in her vision except she's had age-related macular degeneration. Her acuity was 2020-2025. She had no RAPD. She had a very small esotropia. And her visual fields showed a little bit of an arcuate scatoma here and maybe the start of one over here. And when we looked at her discs, a couple things were apparent. The reason she was sent is it looks like this disc is elevated, doesn't it? There's just a little elevation superiorly. And she's got this kind of sub-retinal hemorrhage around the optic disc as well. And it's a little bit hyper-remic. And so she was sent for patholedema. So what do you think about that? Would you like to think about anything else? Well, we looked at all the imaging. She'd been to the ER, so she'd already had an MR. She refused to lumbar puncture. Her blood workup was negative. And we looked at her imaging. And we really could not see any signs of the disc protruding into the globe. We couldn't see any enhancement of the nerve. We didn't see any of the telltale signs that we looked for, which we'll talk about of high pressure like an empty cella or anything else to go along with patholedema. So we elected to do a diagnostic procedure. Does anybody have an idea what that might have been? Ultrasonic. We did an ultrasound. And she had buried drusen. So this case exemplifies that, you know, you can't just say, look at the disc and say, oh, well, it's elevated, so it must be patholedema. You have to think, okay, does she have a history that sounds like something new going in in her head or anything else? The answer is no. So the first question is that really swollen. And optic disc drusen, I would say, really confused the picture as one of the most frequent things that we can run across. It's usually inherited. It runs in families. And of course the word drusen comes from the German word for the inside of a geode, drusen. And it's not hard to pick them up when they're really obvious. And you see these little calcific bodies on the optic disc. Then you go, oh yeah, it's optic disc drusen. And Brad and a previous medical student actually reported that when they looked at OCTs, one of the things that people have always said about drusen is that the optic canal is more narrow. But in that study that they did, they showed that the canal is really not, is a normal sized canal. So there are two flavors of drusen. The easy one is visible drusen. And I like to look for the visible drusen right with the direct ophthalmoscope by using the slip beam, which I can side eliminate the disc or the red free filter, which helps bring them out really a lot more easily. But the ones that give us the fits are the berry drusen. And so clues to anomalous nerves that this person had were that usually it's cupless. The disc is cupless. Now, a cupless disc can swell as well. But when you say a cupless disc, always say could this be an anomalous nerve? The second clue is usually there are anomalous vessels on the disc. Like here's a trifurcation. These are, look at these, you know, vessels are very anomalous peering because like all of them are coming out of the center. You can see these trifurcations and all that kind of thing. And if we go back to that lady, you can see she has a cupless disc and she's got anomalous vasculature. So when you see it, it doesn't mean that you can just say, oh, I'm done. I'll just get an ultrasound and I don't have to do anything. No, you may still have to do something. But what you need to do is just double think it and say, no, is this an anomalous nerve or is this a real disorder? The green filter is really helpful. I mentioned the slick beam and then of course our fluorescence. And here the photographer can be your friend because sometimes they can actually see it with color photos, red free photos. Auto fluorescence really can bring this out. Even if they're buried sometimes you can see it. And then there's a lot of work being done right now on OCTs. Seeing little chatter lines in enhanced depth OCTs to see the object just drew them. So if you suspect it, you can do that. The other thing that I think is so easy is a quick ultrasound. We've got them in there. You just take the B scan and turn the gain all the way down and find the nerve first, turn the gain down and then look for buried juice and then light up Christmas light. The other thing is you can look on a CT scan. Usually they're not present on MR. You often have to look at CAT scan because it's calcific and it's going to show up more easily on a CT scan. One of the problems about doing a CT scan is that they do the Texas toast variety. You might call it Texas toast when they're the thick slices. You might just miss the optic disc altogether. The other one that gets confused for edema is the tilted disc. How many of you have seen a tilted disc? You know what it looks like. It looks a little bit like a cornucopia from Thanksgiving. You could almost imagine a cornucopia coming out and instead of fruit coming out of the end of it it's blood vessels coming out of the end of it. There are many different types of disc versions. You can see these temporally. They can be nasal. They can be pointed inferiorly or superiorly. This one's kind of superior. This one's sort of nasal. Of course they are almost always associated with anomalous vessels of the affected. That's another thing to do. Even on CT sometimes you can see these discs are inserted almost on the side of the globe instead of just straight at the apex of the globe. Another disc that gets always called edema and we see this every day in neuro-othemology is an neurologist looks at it and they see it hyperemic disc. Attention to the tint alone is a tremendous source here. So said William Gower's over the last of 1900 and he said if you pay attention too much to the color of the disc you're going to be misled more times than not. These are just normal discs in people. They're coupless. As soon as you see a coupless disc it should send out a little bit of a okay I got to look at this a little bit more carefully and then you can start to look for abnormal vasculature and that can be helpful in helping you determine that no these are just little what we call little red discs but they're frequently confused for papillodema and these are what we call the disc at risk for ischemic optic neuropathy as people get older or have hypertension and diabetes. They're also sometimes a little bit hypoplastic meaning they didn't fully develop. So these are the ones that can be very confusing. All right now this is another case. This is a 54-year-old man who had blurred vision. He's had a liver and kidney transplant. He's been on some medications, prednisone, arolimus, microfellate, mesymysol because he's got a thyroid problem too. He went to see his dentist for a filling and the next day he had blurred vision, pain with eye movement. He was seen in the emergency room and was diagnosed with papillodema and sent to us. So here's his exam. He was 2300 in the right eye, 2025 in the left eye. He had a big afferent defect in the right eye. His eye movements were full. He had no cell. His visual fields were interesting and that they showed mainly a big blind spot in the right eye but a little bit of central depression in the right eye. The left eye was pretty normal and here are his fields or his optic discs. The first question we asked was is it real edema or not? So what do you think about this? Do you think this is real edema? Right. It's got pretty normal vasculature. You can still see the cup. Frequently the cup is the last thing to fill in true edema. But these aren't normal nerves, right? These aren't normal nerves. What is it that tells you a little bit that this is not papillodema from increased intracranial pressure? What's the feature here? Asymmetry. Okay, asymmetric visual loss and he's got an APD and he's got, you know, he's got poor vision in the right eye as well. And the nerve is swollen in both sides but it is somewhat asymmetric. Is there anything else? Well, I mean, I think the fact of the matter is that I mean, he doesn't have any symptom of high pressure like headache or noises in his head or anything else. So this thing is pretty sensitive here. So he looked at his imaging and there might have been a little enhancement of the optic nerve on the right and he did have a few T2 flare signals but, you know, he had no empty cell and no other signs of high intracranial pressure. And this case brings up the problem about terminology because the ER sent him for papillodema and many people think papillodema is synonymous with bilateral discodema but we reserve papillodema for a edema related to increased intracranial pressure. So if you don't know if it's papillodema or not you could call it discod, bilateral discodema. You could call it bilateral swollen optic disc. The term papillitis is often used for inflammatory causes of optic nerve disorders like an optic neuritis. Choked disc. You might hear that term sometimes. It's a very old term. It was used in the last century for papillodema related to brain tumors because the only way they could diagnose a brain tumor was finally if they had papillodema and they'd say, oh my god, this person has a choked disc and it fell out of favor because the choked disc didn't tell anybody anything. Papillodema is used for increased intracranial pressure with bilateral discodema. Optic ritis can cause edema in about a third of the cases but it's usually unilateral only. Optic ritis is usually unilateral. Neurorutinitis or optic discodema with macular star formation or ODEMS is often unilateral and it usually can follow some kind of viral illness. And then ischemic optic neuropathy is a swollen disc related to usually AION whether it's arthritic or non-arthritic. You will see a unilateral on this swelling. Now I think it's important to understand what we're really talking about when we're talking about a swollen disc. We're talking about mechanisms of axonal swelling and this little cartoon I'll take you through what this means. This is like a ganglion cell attached to an axon and it's representing all axons that are going from the retinopathy. It's a little wormy thing. This is the laminocobrosa which it has to traverse. It picks up its myelin behind the laminocobrosa and really there's a combination of the intraocular pressure plus the intracranial pressure that plays a role in discodema. So in increased intracranial pressure when the pressure is elevated in the intracranial space it causes axoplasmic stasis and that stasis occurs at the laminocobrosa and that keeps and it causes sort of the swelling to occur. Now in ischemic optic neuropathy usually we think of that as something happening right at the laminocobrosa and you have these toxic anoxic effects or infarction it's also going to cause axoplasmic stasis. So when you see edema there's like an axoplasmic stasis. Inflammation does something similar and if you see hypotony because you can see a swollen nerve with hypotony where the pressure in the intracranial space is normal but the intraocular pressure is so low that the axoplasm cannot flow that'll cause stasis as well. So these are the basic mechanisms of exodermal scone. In features of true swelling I always look for swelling of a nerve fiber layer. Now the way to do that is again with your red-free light or the green light is really helpful at looking at the nerve fiber layer and I think one of the most helpful signs is obscuration of the vessels on the edge of the disc just obscuration of the vessels because in true swelling the axons will swell and then they'll obscure features on the optic disc. So this disc for example you can't even see where these vessels are. They're somewhere buried in all of this axoplasmic stasis. Looking for elevation and ophthalmologists are really good at using indirect ophthalmoscopy to see the 3D effect of true elevation. When you're using the direct sometimes it's a little harder to see because you're monocularly viewing but you can still see elevation even in this photo you can see that this there's a rise coming up here you can see that this is an elevated disc. The cup is usually maintained until later in disc swelling it's not the first thing to go and of course we often like to look at the loss of the venous pulse I like to look for the presence of the venous pulse because it's a little bit of a good finding in that you kind of think that the pressure is not elevated although there are cases where venous pulsations were present and the intracranial pressure was 300 or 400 so you can't completely hang your hand on it but it's a helpful sign. The color I don't think is helpful retinal folds I always look for those because they're helpful sometimes but they're not specific like you can see retinal folds from a mass that's pushing on the back of the globe and you can get retinal folds from other things, hemorrhages and nerve fiber layer infarcts you can get that from diabetic retinopathy so they're not a completely helpful finding but they're incidental the patent's lines are probably the most helpful how many of you have seen patent's lines? not? a couple people have okay so you look at the edge of the next time you see a truly swollen a deminous nerve papillodema look around the disc and just see if you can see these little tiny lines right here they're almost like little stretch marks that have occurred they're not as dramatic as caroidal and retinal folds they're not that dramatic they're much more so but look for it next time because sometimes they're present they can be helpful but they're not always specific hemorrhages of any type can happen with papillodema or with any dysphelin these are all four cases of papillodema actually but you can see pre-retinal hemorrhages nerve fiber layer hemorrhages et cetera and the same with cotton wool spots I always look at the macula with every swollen nerve to see if there's any deposits in Henley's layer to help us understand that there could be a macular star present and then just to kind of review how are you going to tell the difference between papillodema and other forms of diswelling like that that I showed you on the history headaches, transient visual aspirations blurred vision, maybe present in papillodema whereas this will be visual loss visual acuity is usually normal in papillodema until the end visual acuity is almost always effective in let's say optic neuritis, AIOF in papillodema there's usually no RAPD yes it's highly asymmetric and in optic neuritis and ischemic optic neuropathy RAPD is almost always present if one side is more than the other and in papillodema you may see no other visual field defect than just in a large blind spot whereas in optic neuritis and ischemic optic neuropathy you frequently have other visual field abnormalities and both of these can cause pallor so we'll go back to that case that I brought up to you the guy who had the liver transplant kidney transplant he had the MR, he had ALP his opening pressure was 14 centimeters or 140 millimeters and he was on everolimus which has been shown to cause press and the thymazole which has also been shown to cause diswelling we stopped the drug, treated with steroids and then he went on a different limus drug and he's done fine but there are many drugs that can cause disque swelling the limus drugs nasal congestions the rectal dysfunction drug you should be aware of those can cause EIOM and then amiodermal causes kind of a toxicity to axoplasmic flow and can give people swelling but it's not a true ischemic optic neuropathy now we've got a 22 year old woman with her headaches completely different than all these other people she has had chronic headaches for three months and she recently gained weight and she's had some blurring of revision and she sees her optometrist who does not do any further work up and so the work up got a little bit delayed she noted some dimming of revision, her acuity was down and she finally got an MRI scan and then she finally got a neuroaphthalmic exam and she had an elevated pressure on her lumbar puncture and she had bilateral papillodema with pretty bad visual fields and we'll talk a little bit about hyperacute integrinohypertension as well so papillodema is caused from increased integrino pressure and it's most commonly bilateral but don't get fooled, it can be unilateral I'll show you the case it can be various grades and I'll take you through all the grades and it should signal an emergency so if you really do diagnose papillodema that person gets an MRI scan and a lumbar puncture or whatever we need to make work of the problem but that's an emergency, you have to really get to the cost you can't just sit on this, you have to move now large phrysanne came up with a scale of the grades of papillodema and so it's zero to five and zero is minimal swelling of the disc now this is a woman who I saw, she had a good path to get integrinohypertension her opening pressure was 340 so not low and this is the amount of swelling she had almost not I would have a hard time saying that that was a swaner and even if you do OCTs which is a beautiful article in high OVS from 2012 that takes you through OCTs there's sand scales and optic disc photos it's really a nice article but this is great, stage zero minimal swelling the nerve fiber layer the axons are not that constipated there's no vessel obscuration the cup is totally present and not obscured stage one D-shape swelling this is an early kind of swelling and the nerves that are going to swell at the first are going to be at the superior and inferior because that's how the nerve fiber layer comes into the disc superior and inferior and everybody goes oh there's some nasal blurring well the first place to look it's really superior and inferior and then nasal and then temporal and then nasal swell you can see these little folds in there I'm just pointing those out for you and the temporal margin is usually normal and sharp and that's why it's called C-shaped swelling and the cup is maintained to the very end no in stage two it's 360 degrees of swelling 360 degrees of swelling but notice that the cup is still present it's not completely obliterated in stage two and there's very little vessel obscuration maybe some of these little inbitty ones along that very edge are a little bit obscure but you can see most of the blood vessels easily stage three again 360 degrees of swelling and here the nerve fiber layer starts to look kind of whiteish or whitish because it's really constipated there's a lot of stasis going on the disc may be hyperemic or not but maybe and this is the stage where you see a lot of vascular obscuration at the disc margin so if you look at the disc you're going to just see that you can't see almost any of these vessels at the disc margin you still can see the bigger vessels on the disc but you lose the ones at the disc margin and the cup may be completely filled in in this case you can still see the cup sort of look but stage four the cup has got obliteration of the cup and opaque vessels most of the vessels are opaque on this disc there's often advanced hyperemia and vessels are you really have a hard time seeing them I don't know if you can see it from where you're sitting but there are some patent lines along this disc can you just see those little they're really fine patent lines so next time you see a really swollen nerve look for patent lines and then stage five we call the champagne quart swelling this is chronic swelling that's been there for a long time I've not seen this very frequently usually people have checked up before it reaches this stage but I've seen this a couple times this guy had a shunt that malfunctioned and he just went around like this for a long long time and again no vessels are seen there's no cup but it does really look like a champagne quart that's just sitting in the back of the eye now how can you tell if somebody's had swelling in the past and you can look for signs of atrophy or atrophic swelling and there you get this kind of glial look it just looks fuzzy I call it fuzzy pallor and the other thing you can look for are high water marks you know they look like little rings like bathtub rings from you know the dirty bath temple but these high water marks can sometimes give you a clue so if somebody comes in and they don't have a swollen nerve now but boy their history sounds like they could have had a swollen nerve you could look for those findings this was a case that was a real fool for many for some of us the nerve on the right was almost completely normal you could argue that there was here and here but she had this really swollen nerve on the other side and she ended up being idiopathic endocrine on my pretension finally somebody we did a little more puncture and diagnosed this as the demon from increased endocrine infection the nerve once it's swollen and the pressure is relieved either with medications or surgery or whatever you start to regress and again you can often see these high water marks once it regresses and sometimes the nerve does become a little bit pale or you have that little fuzzy power now I always think that the MR is my friend it's an adjunct to everything that we do in neuroanthropology besides looking at the nerve and admiring it and looking at vision and all the aspects of the MR can be our friend as well so there's just some things that I look for on every single patient that I suspect Papillodema I first look at an axial and I look to see if I can see the disc protruding into the globe I look for flattening in the back of the globe and I look for excessive fluid along the optic nerve these are findings that can occur with true papillodema I also always look at the sagal for an empty cell or a partially empty cell and we can look for tortuosity of the optic nerve of the optic nerve and we can look for narrowing these days most people get an MR and an MRV when they're working somebody up for the eukaryotic cranial hypertension and we just did a study that's in press right now where if you've got three of the four of these you've got a pretty high chance of it being true increased in cranial pressure empty cell flat posterior globe distention or tortuous optic nerve sheath and transfers phenocynous stenosis and if you have three of the four of those you've got a pretty good chance that it's raised in your brain. Dr. Harry does a great job with a 30 degree test in kids for example if they are brought in and you don't want to sedate a kid and do the LP I might do this first if I'm not even sure if the pressure is up I might get an ultrasound because it can show buried drusen in addition to doing a 30 degree test to lower the pressure because he measures the nerve in one gaze and then he measures with the nerve with the eye pointing to a different gaze and that's called the 30 degree test that he's going to do yet. Now just because you diagnosed papillodema finally doesn't mean you can sit back and just say oh I've got papillodema going on here you've got to find out why and it could be there are many causes of papillodema from increased CSF production and that could come from a coroid plexus papilloma where these papillomas start making CSF fluid and that can raise the pressure you can have decreased CSF absorption through the arachnoid granulations you can have increased venous pressure from either thrombosis or stenosis and you can have obstruction through the normal CSF pathways through the aqueduct and so you always want to be thinking about some kind of obstructive thing and of course everybody's worried about a mass lesion in the brain and causing papillodema How often do you think papillodema actually occurs with a brain tumor? Well it's a little bit more than that but it's like 20 to 30 percent How often do you think papillodema occurs in somebody with documented intracranial hypertension from traumatic brain injury and you looked at them every single day in the ICU to see if they are developing papillodema that study has been done again it's not that often 20 to 30 percent a mass of the tumor is more likely to cause a seizure than papillodema Is that okay? I do want to mention glymphatics these have been known for about 100 years they are sort of the lymph flow of the brain and they may play a role in stopping egress through the arachnoid granulations and cause more stenosis of the venous sinuses out on this about the venous glymphatic connections and what role they play in intracranial hypertension So now when I think of papillodema and raised intracranial pressure and I've gotten an MR and I don't see a mass lesion I don't see aqueductal stenosis I don't see hydrocephalus I don't see anything wrong on the MRI scan and the spinal fluid is normal so it's not meningitis or encephalitis or any of those things I am left with is this primary intracranial hypertension or an idiopathic intracranial hypertension or is this a vascular that looks exactly like and caused by another reason okay? and so like secondary things like venous sinus thrombosis can present identically with idiopathic intracranial hypertension in addition some medical disorders can look identical like hypoperothyroidism sometimes can present with raised intracranial pressure and papillodema a rarely right heart failure sometimes the batnia we have seen iron deficiency anemia you have to be really low on your iron I mean like a hemoglobin of 6 to get it I don't want to see it and medications tetracycline, minocycline are really really common growth hormone, vitamin A and lithium noreplant is kind of a controversial association as is marina IUDs and some of the other things like leudron et cetera but there's a whole list of drugs that are raised intracranial pressure the lumbar puncture as I said is a must you have to do it normal pressure is less than 200 200 to 250 is kind of like glaucoma right 200 to 250 is sort of like well borderline and I usually say 250 is my normal cutoff and sometimes I say it's normal even if it's 287 if there are no other findings there's nothing else they just have a raised ICP because there's so many things that can affect the pressure if they're curled up in a ball and doing a failselva maneuver you know I mean nobody likes an LP but you know you have to curl up in a ball and you know you're kind of tense and you're going well you can raise your pressure to 300, 400 you by yourself sitting here right now could do that if you wanted to just doing a big failselva maneuver you always have to look at the protein glucose cells you can't just do the lumbar puncture and get a pressure sometimes pressures are done in the prone position it's pretty good it's a few millimeters difference in the prone a little bit higher in the prone than on a side but it's significant and I always like to remember that even people with migraine and headaches can have a little elevation of their intracranial pressure that's a whole other topic but I'm not going to get into so I always I don't worship the pressure alone but I do, we have to do it now can you use the loss of a headache from a lumbar puncture to find that ventracranial pressure hypertension well there have been studies that have shown in IIH that if you do an LP about 72% of the people with true IIH do get benefit from the lumbar puncture but chronic headache patients often get the same benefit from a lumbar puncture and this study that was recently published this year showed that yes a lot of people get improvement of the headache but many people get worsening of the headache right away they'll get a post-LP headache right after they get the lumbar puncture so it's not like a treatment for a headache you've got to do visual fields I just want you to hammer that in I had somebody from Wyoming call me about race intracranial and thought it was Pamela D. Meiss well what did the visual field show they haven't done a field they haven't done a field okay you've got to do a field okay that you cannot follow visual acuity in this disease in this disease at all you've got to do a field because the acuity is the last to go you've got to do a visual field now the types of visual field defects that you'll see are usually peripheral not sensual usually peripheral in large blind spot is probably the most common visual field defect and then you can see these argument defects you can see constriction of the field you can see wedge shaped defects but you've got to do a visual field now what causes visual loss with Pamela D. Meiss well if you've got really high grade Pamela D. Meiss or losing vision if the nerve infarcts you know if you've got axoplasmic stasis you're squeezing those little blood vessels and you infarct the nerve you're going to lose vision and other things can affect the blood flow to the disc like hypotension so somebody who undergoes renal dialysis and he has wide fluctuations of the blood pressure they are at high risk for visual loss you can occlude your central retinal arteries you can even get a central retinal vein infusion there was one study done a guy was in a car accident and he had IIH and they did a autopsy on him and what was shown was severe axonal loss in the peripheral area of the nerve and the nerve receptors were normal so the area that seems to be most susceptible are the peripheral portions of the nerve and if you've got raised intraocular pressure sometimes people call that a double crush you're getting it from one end and you're getting it from the other end and then if they have buried drusen or optic pits that's another thing that can make visual loss more frequent and then folds and etc and then don't forget functional visual loss can also occur are there any things that can predict visual loss? well our recent weight gain highly papillodema law standing papillodema a trophic papillodema papillodema that's been there for a long time not recognized that's a recipe for problems delay in treatment and then visual loss is the most helpful sign in a recent study that came out hypertension men tend to lose vision more especially African American men often because they don't come in and get seen early enough older people seem to be at higher risk and people with high intraocular pressure a lot of the symptoms do not predict visual loss and for sure the headache does not tell you whether they're going to lose vision or not the treatment of this disorder is usually diamox but methozolamide or anectosine can also be used with diamox you have to wash for kidney stones, anemia, renal failure all these different things all of you should be familiar with the IIHTT it was the first randomized control trial with diamox versus placebo in 165 patients enrolled the average diamox dose was 2.5 grams and this was mild to moderate visual loss and they looked for treatment failure by worsening of two decibels in either eye and their primary outcome was the visual field and it did meet the primary outcome just barely that the acetazolamide plus diet was better than placebo and diet more most of these people lost weight more weight than the acetazolamide group and their papillodema also got grades got better but their headaches did not it didn't matter which group you were in the headaches stayed about the same I'm going to skip headache in this disorder but weight loss definitely you've got to counsel your patient on weight loss and the best treatment for headache is probably a diuretic glycosidazolamide sometimes a migraine preventive or to pyramid if they've got very mild visual loss to pyramid can also be used it's a weak carbonic anhydrase inhibitor but in the small series with animal models it showed it lowered the pressure more than acetazolamide in this animal model so I use this for people who are very mild papillodema but lots of headaches I'll treat migrates with it to pyramid steroids we really don't use those very often except in unusual circumstances and all these other drugs just don't seem to work as well or expensive there are surgical treatments and we're going to be undergoing a surgical treatment study here at the Maran where we're looking at optic nursing fenestration versus venous or ventricular peritoneal shunt and looking at visual outcome versus best medical therapy and this is a nice review of the different surgical procedures optic nursing fenestration, lumbar peritoneal shunts ventricular peritoneal shunts and stemting stemting is where they put a foreign body into the vein so a problem with that is you're putting a foreign object into your vein forever and that can reach to those so it does work in certain cases and we have sent people for that what I did want to make sure that you know about is fulminant IIH this one is you get a call, you've got somebody with a bad capital edema usually and often they haven't been diagnosed early enough and they've already got horrible visual loss and the problem with this is that 8 out of 16 people in this series were legally blind at the end of it so this is an ocular emergency and we've got a protocol for this if you diagnose optic nerve edema due to increased intracranial pressure ophthalmology is supposed to be consulted and we're supposed to be looking at the field and all that if they've got field loss they get admitted for a lumbar drain to temporize things for an optic nerve sheath fenestration or for ventricular period male shunting and if one doesn't work sometimes we try the other as well all of you know about novel but there are handouts for patients on pseudotomers cerebrite and several in multiple languages if you have something with a different language you can still use it because it will last 5 minutes I'm sorry it was through the back part but if you have questions on this I'm happy to keep them so I've got a few questions and I'll give you this story question number one is this papillodema so this is a 34 year old woman she has chronic migraines she's had her whole life and a neurologist looks in and sends this patient to you is this papillodema she has no dimming her vision, no TBOs nothing else is this papillodema and you can say yes or no and then tell me what it is this is a 9 year old asymptomatic boy he was seen by his optometrist for school vision screening and sent emergency for papillodema and is this papillodema yes or no did you need to look at that some more this is a 35 year old woman who had transient monocular visual loss in her left eye headache, noises in her head what is this one is this papillodema no visual loss no TBOs in the left eye no APD 4 on the left a papillodema or a pseudo papillodema and 5 is the same question so describe 3 tests that you would order to evaluate and work up papillodema and the 3 causes of papillodema was 2 medical treatments for papillodema and then those 2 surgical treatments for papillodema all my questions followed my objectives at the beginning of this lecture this is really fast you're going very fast oh is it too fast do I need to go back yeah okay let me go back okay this is the 34 year old woman chronic migraines forever a neurologist looks in and says sends her to you because wants to know if this person has papillodema no other demos, no other visual symptoms totally ruin the exam except looks like this 9 year old asymptomatic boy goes to a septometrist he just had a school screening in Sam and sent for a bilateral path with you and is it or isn't it and if and maybe what is it okay 4 you're just looking at the disc ready to go on everybody ready okay and then all of these are just on one slide okay are we ready to go through these ready first one Becca what do you think I think so first of all we're only looking at one disc we're only looking at one but let's assume that they both look the same I think it looks like this margin are I mean you can see the vessel is pretty clearly it doesn't really look like papillodema and it doesn't fit with it cup-less disc anomalous vasculature and the story is just she's got chronic headaches and she's having fruit ever and ever and ever without any visual fines okay that's true do you know what this disc is called remember a little red disc it's just kind of hyperamic cup-less little red disc okay how about this one I'm not sure about this one so although there's changes around I feel like I can see part of it is at least on the right eye the left eye I can't see quite as much I was wondering if it was like so I could see the vessel and vasculature very well throughout can't really make up and look at what it looks like footballs you know an optic disc doesn't look like a football when you see football looking discs then think something anomalous what do you so do you think this is papillodema do you have any idea what he probably did have anybody he had very drusen these football discs you see a football looking disc and get that ultrasound out and look for drusen okay but it's anomalous I mean it's cup-less you see all the blood vessels they're coming out kind of straight and he's got like trifrications I mean here's a nice trifrication right up here I mean once you see these anomalous vasculature funny looking shape be thinking about another cause okay how about this one she's got asymmetric papillodema you can see maybe a little bit of swelling over here a grade one if you were going to grade this these grades aren't perfect it's like about yeah she's almost lost all of her big vessels almost all of her little ones at the edge of the disc pretty much so yeah I would definitely think that this was kind of between a three and a four it's not completely obscured all the blood vessels on her disc but it's pretty close all right how about four it's pseudo papillodema the vessels are probably nice okay and also there are drusen here if you can see though a little so drusen okay how about this one I would say that's papillodema okay for sure disc swelling yes we were talking about papillodema but for sure disc swelling yeah I was just going with the insurances all right well that's good okay what about three tests you in order to evaluate so we can do an LP and MRI yeah those are the three big ones I mean there are other things you could have said but those are the three that you should always order MR and always do the MR first then do the LP but always get a visual field so that should be a great sure you do that okay how about three causes of papillodema do you have any do you have IIH IIH an intracranial mass like a brain tumor well you can get help from your colleagues venous sinus thrombosis a hydrocephalus corioplexus papilloma aqueductal stenosis etc okay all right now we're back to are you guys participating okay two medical treatments for papillodema acetylzolomide okay good acetylzolomide methazolomide to pyramid could be a treatment especially if they have low-grade papillodema with more headaches that would be good and what about two surgical treatments optic nerve chieftain temporal temporal decompression you could do that but do you know what that is okay you take off your skull isn't this a treatment that we don't do so don't we don't do that very much anymore but that's true it's something that could be done so are the most popular things are ventricular peritoneal shunting optic nerve chieftain fenestration and I would say venous stemting would be another treatment that you could offer in certain cases but you'd have to be sure that when the pressure is raised it will collapse the veins so that will cause the venous genosis and so you want to make sure it's a fixed venous genosis and that there's a pressure gradient across the vein because you don't want to stem somebody that if you just do an LP on them or a ventricular shunt that vein just opens up you don't want to put a foreign body in somebody I've seen people get stents and they had severe iron deficiency there was nothing wrong with their veins but it caused raised intracranial pressure pressed on their veins and then they put a stun cam well she's got a foreign body in her vein for the rest of her life giving her chronic headaches and all kinds of stuff so okay good good job