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 Discussion 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. References 1. Miller NR, Newman NJ. Walsh and Hoyt’s Clinical 8. Lorentzen SE. Drusen of the optic disc. Acta Neuro–Ophthalmology, 5th ed, vol 1. Baltimore: Ophthalmol 1966;90(Suppl):1-180. William’s and Wilkin’s: 1998;803-16. 9. Friedman Ah, Henkind P, Gartner S: Drusen of 2. Claudia A H, Flemming S, Heinrich W. Optic Disk the optic disc. A histopathological study. Trans Drusen Surv Ophthalmol 2002;47:515-32. Ophalmol Soc UK 1975;95:4-9. 3. Joy M. W, Howard D.P. Visual manifestations of 10. Reese A. Relation of drusen of the optic nerve visible and buried optic disc drusen. J Neuro- to tuberous sclerosis. Arch Ophthalmol Ophthalmol 2004;24:125-29. 1940;24:197-205. 11. Kiegler HR. Comparison of functional findings 4. Rosenberg MA, Savino PJ, Glaser JS. A clinical with results of standardized echography of the analysis of pseudopapilledema, I: population, optic nerve in optic disk drusen. Wien Klin laterality, acuity, refractive error, ophthalmoscopic 1995;107:651-3. characteristics, and coincident disease. Arch Ophthalmol 1979;97:65-70. 12. Boldt HC, Byrne SF, DiBernardo C. Echographic evaluation of optic disc drusen. J Clin 5. Savino PJ, Glaser JS, Rosenberg MA. A clinical Neuroophthalmol 1991;11:85-91. analysis of pseudopapilledema, II: visual field 13. Erkkila H. Optic disc drusen in children. Acta defects. Arch Ophthalmol 1979;97:71-5. Ophthalmol 1977;129(Suppl):3-44. 6. Cartlidge N E F, Tilley P J B. Dilemma of the 14. Mustonen E. Pseudopapilledema with and swollen optic disc: a fluorescein retinal without verified optic disc drusen. A clinical angiography study. British Journal of analysis I. Acta Ophthalmol 1983;61:1037-56. Ophthalmology, 1997;61:385-89. 15. Mustonen E. Pseudopapilledema with and 7. John E.C, Michael D. M, Barry M, B. without verified optic disc drusen. A clinical Pseudodrusen of the optic disc. J Clin Neuro- analysis II: visual fields. Acta Ophthalmol Ophthalmology 1989;9:273-76. 1983;61:1057-66.
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