Headache For Patient and Clinician Optic Disc Drusen Masquerading by ory15526


									                              NEURO OPHTHALMOLOGY SESSION                                        349

    Headache: For Patient and Clinician Optic Disc Drusen
               Masquerading as Papilledema
Dr. Vishal Shah, Dr. N. Jayakumar, Dr. S. Ambika, Dr. V. Noronha, Dr. P. M. Sundaram

P    apilledema is defined as disc edema
     secondary to increase intracranial pressure
where as pseudopapilledema is an anomalous
                                                    excluded if they had a coexisting ocular diagnosis
                                                    that potentially affected the above parameters
                                                    or lacked a definitive ultrasonographic evidence
optic disc elevation that simulates papilledema.1   of optic disc drusen. Presenting symptoms were
The      difficulties      in    differentiating    categorized as asymptomatic or symptomatic
pseudopapilledema from papilledema are well         (visual disturbances or headache). Refractive
known to ophthalmologists and neurologists. It      status was tabulated as emmetropic, myopic,
becomes even more difficult when patients present   hypermetropic and those having only astigmatism.
with symptoms such as headache and visual           Indirect ophthalmoscopy and +90 D slit lamp
disturbances. Optic disc drusen is one of the       biomicroscopy with red free filter was done for
most common causes of pseudopapilledema.            all eyes. Optic discs were evaluated for degree
The majority of optic disc drusen cases have        of elevation, blurring of margins, anomalous
been benign in nature. However optic disc drusen    vasculature and obscuration of peripapillary
can be visually devastating. The decision to        vessels. Humphrey visual fields were used to
undertake expensive neuroradiological               assess field of vision and were categorized as
investigations is entirely dependent upon a         normal or having field defects. Buried drusen
correct interpretation of the disc changes.         were confirmed by B-scan ultrasonography, which
The objective of the present study was to           showed a highly reflective echographic signal
characterize the visual manifestations and          persisting at low gain setting.
clinical characteristics of patients with optic     Results
disc drusen.
                                                    Complete records of 51 eyes of 28 patients
Materials and Methods                               with ultrasonographic confirmation of optic disc
We retrospectively studied the records of all       drusen were reviewed. Of the 28 patients, 12
patients with a diagnosis of optic disc drusen      were males and 16 females. Age ranged from
confirmed by ultrasonography. The cases were        3 – 57 years (Mean 28.89 years). Involvement
analyzed with respect to age, sex, laterality,      was bilateral in 22 and unilateral in 6 patients.
presenting symptoms, visual acuity, refractive      In these unilateral cases, there was involvement
error, ophthalmoscopic appearance of the optic      of right eye in 4 and left eye in 2 patients. 14
nerve head and visual fields. Patients were         patients were symptomatic presenting with either
 350                                   AIOC 2006 PROCEEDINGS

visual disturbances (11) or headache (10). Of         who presented with headache had bilaterally
these 10 patients who presented with headache,        elevated suspicious looking discs causing
8 patients had bilateral elevated discs. Visual       confusion between pseudopapilledema and
acuity ranged from 6/5 to 6/12. One eye had           papilledema. Visual acuity was preserved in
very poor vision (counting fingers) due to a          all patients (6/5 – 6/12) as reported in other
corneal opacity. 35 of the 50 eyes had a refractive   studies.8, 14 In 1961, Rucker and Kearns pointed
error with myopia in 23, hypermetropia in 9 and       out the fallacy of assuming that diminution of
astigmatism in 3. Mean IOP by applanation             visual acuity may be attributed to optic disc
tonometry was 14.17 mm of Hg. All eyes had            drusen. 70% patients had a refractive error
suspicion of buried optic disc drusen with either     (65.7% myopic, 25.7% hyperopic and 8.5% had
disc or margin appearing elevated. 18 eyes            astigmatism). Specifically, we found no increased
had blurred margins and 8 eyes had anomalous          incidence of excessive hyperopia as reported
branching of vessels. Fields had been done for        by Lorentzen.8 All cases considered here had
12 patients (24 eyes), of which 13 eyes had           elevated (disc or margins) or suspicious looking
field defects and 11 had normal fields. There         optic discs. 36% eyes had blurred margins and
were 9 patients who had been referred to our          16% had anomalous branching of vessels. None
institute with a misdiagnosis of papilledema          of the other vascular complications like retino-
and had already been thoroughly investigated          choroidal collaterals, anterior ischemic optic
by CT scan and MRI which were normal. These           neuropathy, central retinal artery/vein occlusion,
patients were subsequently examined at our            subretinal neovascularization or retinal
institute and diagnosed as having optic disc          hemorrhage were seen in any of the patients in
drusen.                                               our series. In this study, fields had been done
                                                      for 12 patients (24 eyes) of which 54% had
                                                      field defects. This figure is higher as compared
Optic disc drusen occurs in 3.4 to 24 per 1000        to other studies like Wilkins et al (36%) 3,
population. 8,9,10 In our study, a slight             Mustonen (48%) 15 and Savino et al (25%) 5. Of
preponderance of females (57%) as compared            these 28 patients, 9 patients had been referred
to males (43%) was noted which was in                 to our institute with a misdiagnosis of
accordance with recent studies.11 The age range       Papilledema. Thus, a careful ophthalmoscopic
was 3 – 57 years (Mean - 28.89). According to         examination supported with ultrasonographic
literature reports, the youngest child in whom        confirmation can avoid the misapplication of
buried drusen were detected by B-scan                 unnecessary and potentially morbid invasive
sonography was 4 years old.2 In our study, we         neuroradiological investigations and even
report the case of a 3-year-old male child brought    neurosurgical procedures. To achieve a correct
to us with a single episode of vomiting after a       diagnosis, the signs of papilledema should not
fall and was diagnosed at our institute to have       be overlooked: swelling of the adjacent
bilateral optic disc drusen (confirmed by             peripapillary nerve fibre layer, mild telangiectasia
ultrasonography). This may be one of the              of the superficial vessels of the optic disc and
youngest reported cases of buried disc drusen         obscuration of the retinal vessels as they cross
with ultrsonographic confirmation. Bilaterality       the border of the optic disc. In most unclarified
was seen in 78.5%, which is similar to that           cases of papilledema, optic disc drusen can be
reported in other studies. 8, 12, 13, 14 50% of the   detected by ultrasonography, less often by
patients were symptomatic (visual disturbances        neuroradiology. Computerized tomography and
– 78.5% and headache –71.4%). 80% of those            fluorescein angiography can also help in cases
                                   NEURO OPHTHALMOLOGY SESSION                                            351

where a dilemma exists.                                    misdirected diagnostic maneuvers but also to
A correct diagnosis of optic disc drusen is                avoid overlooking genuine neurologic disorders.
mandatory although no effective treatment has              Patients need to be aware of potential
been established. It is most important to                  complications and regular examination should
differentiate optic disc drusen from papilledema           be carried out in order to recognize accompanying
not only to avoid unnecessary alarm and                    complications.

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