AKT · Ophthalmology/Neuro-ophthalmology

Papilloedema

Bilateral optic-disc swelling from raised intracranial pressure

Overview

Optic-disc swelling caused by raised intracranial pressure — by definition BILATERAL. It is a sign, not a diagnosis: the task is to find and treat the cause (space-occupying lesion, idiopathic intracranial hypertension, venous sinus thrombosis, meningitis, malignant hypertension). Vision is preserved early but chronic papilloedema causes progressive field loss.

Recognise

Bilateral optic-disc swelling: blurred disc margins, elevated disc, loss of spontaneous venous pulsation, peripapillary haemorrhages
Headache (worse on waking/lying/Valsalva), nausea/vomiting, transient visual obscurations, pulsatile tinnitus, diplopia (VI palsy = false-localising sign)
Enlarged blind spot; central acuity preserved until late

Red flags

Papilloedema + focal neurology → urgent neuroimaging for a space-occupying lesion/haemorrhage
IIH with progressive field loss → urgent treatment to save vision; consider CVST

Differentials & how to tell them apart

Optic neuritis (papillitis)usually UNILATERAL with pain on movement, RAPD and early visual loss

Pseudopapilloedema (optic disc drusen)'lumpy' disc with no true swelling, normal blind spot, autofluorescent drusen

Malignant hypertensiondisc swelling with AV nipping/haemorrhages and very high BP

Anterior ischaemic optic neuropathyunilateral pale swollen disc with altitudinal field loss

Papilloedema — optic-disc swelling with blurred margins
Jonathan Trobe, M.D. / CC BY 3.0 — Wikimedia Commons

Investigations

Urgent neuroimaging (MRI/CT + venography to exclude mass/CVST) FIRST, then lumbar puncture for opening pressure (raised) and contents (only after imaging excludes a mass). Visual fields; BP.

Management

Urgent neuroimaging to find the cause; treat the cause (e.g. acetazolamide for IIH)

1Treat as raised ICP: urgent neuroimaging (MRI + venography) to exclude a mass or venous sinus thrombosis.Gate: Do NOT perform lumbar puncture until imaging has EXCLUDED a space-occupying lesion (coning risk); LP then confirms raised opening pressure in IIH
2Cause-specific: IIH → weight loss + acetazolamide (± shunt/optic-nerve-sheath fenestration if vision threatened); tumour → neurosurgery; CVST → anticoagulation; monitor fields to protect sight.

Acetazolamide — reduces CSF production in idiopathic intracranial hypertension

Treat the cause — tumour, CVST (anticoagulation), infection, BP — disease-specific

Key points

Bilateral disc swelling = raised ICP until proven otherwise. Image before you LP. Central vision is preserved early — an enlarged blind spot and field loss are the warning signs.

Monitor & prognosis

Serial visual fields and disc appearance; treat the cause.

Vision preserved if pressure controlled; chronic papilloedema causes atrophy.

Source: RCOphth; NICE (IIH); neurology guidance