Papilledema is swelling of both optic discs caused by raised pressure inside the skull. It is a warning sign of a tumor, bleed, venous sinus thrombosis or idiopathic intracranial hypertension, and it needs urgent workup.
Key symptoms
- Headache, often worse lying down or in the morning
- Nausea and vomiting
- Brief graying or blacking out of vision lasting seconds
- Whooshing sound in the ears that pulses with the heartbeat
- Double vision
What you find on exam
- Fundoscopy: blurred disc margins, raised discs, loss of venous pulsations
- Both eyes usually affected
- Visual acuity often normal early; enlarged blind spot on visual fields
- Sixth nerve palsy: trouble moving the eye outward
- Full neurologic exam and blood pressure
Tests
- Urgent brain imaging: MRI with MR venography, or CT if MRI is not available
- Lumbar puncture after imaging: opening pressure and CSF analysis
- Formal visual field testing
- Blood pressure to rule out a hypertensive emergency
Treatment basics
- Treat the cause: tumor, bleed, venous sinus thrombosis, infection
- Idiopathic intracranial hypertension: weight loss and acetazolamide
- Stop drugs that can raise pressure, such as tetracyclines or excess vitamin A
- Optic nerve sheath fenestration or a shunt if vision is threatened
- Close follow-up with visual fields
Red flags
- Drowsiness, seizure or focal weakness
- Rapidly falling vision or visual field loss
- Very high blood pressure with headache and confusion
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.