Monday, April 08, 2013

Papilledema pearls

1. Cotton wool spots OFF disk may suggest hypertensive syndrome
2.  Hemorrhages off disc suggest central retinal vein occlusion
3.  New onset pulsatile tinnitus is significant finding indicating need to look for increased ICP, as well as transient obscurations, graying of vision for twenty seconds, with postural change and headache.  Field before acuity is affected, disc edema usually affected.
4.  MRI findings  may include disc enhancement, occassionally, enhanced perioptic space (40 %), flattening of posterior globe (80 %), empty sella  Get MRI/MRV
5.  Check blood pressure
6.  Blood:  CBC, electrolytes for Addison's, Ca for HPT, ANA for lupus that is it..  Lumbar puncture always.
7.  Must check visual fields  since acuity is preserved. That is affected early.
8.  Protect optic nerve function and appearance: the two goals of management of pappilledema, not normal pressure, that is not a goal.
9.  Therapy:  diamox 500 bid to start, add Lasix 40  mg q am with Kcl 20 meq.
10. Fenestration protects eye, but does not lower headache or pressure.  Consider fenestrating patients with progressive visual loss, severe loss early, patients with severe papilledema at risk for hypotension (dialysis) or patients unable to comply with monitoring vision.  Shunt is a better treatment for headache of IIH.
h't Valerie Purvin AAN 2013

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