Papilledema (Swelling of the Optic Nerve): Is It Dangerous?

Swelling of the optic nerve or papilledema is dangerous. It occurs when a person suffers an injury or has an underlying condition that is life-threatening. 

What Is Papilledema?

To define papilledema, you first have to understand how it develops and affects the optic nerve. The optic nerve represents the second cranial nerve (CN II). This nerve relays visual details from the eyes to the brain.

When the optic disc (part of the optic nerve within the eye) becomes swollen, it’s due to increased pressure around and inside the brain or from intracranial hypertension (IH).

The condition may develop quickly or gradually. It just depends on the underlying health cause. 

The swelling is normally bilateral or typically affects both eyes. If the condition is not treated as soon as possible, the increased brain pressure may lead to permanent neural damage, vision loss, or death.

Therefore, increased pressure in and around the brain, known as increased intracranial pressure, leads to swelling of the optic discs, or the optical nerves inside the eyes. This is papilledema.

Papilledema vs. Optic Disc Edema: How Are They Different?

Don’t confuse papilledema with optic disc edema. The two are not the same. While both conditions lead to swelling of the optic disc, papilledema develops from increased brain pressure because of an underlying cause. Also called pseudopapilledema, optic disc edema happens when the optic nerve is damaged.

Papilledema usually affects the patient’s peripheral vision and causes changes in visual acuity or later in the central vision. Conversely, optic disc edema affects the central vision initially. As a result, the patient has difficulty distinguishing shapes and objects.

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What Are the Causes of Papilledema?

Papilledema may develop from one of various conditions, injuries, or diseases — all events that increase intracranial pressure. If a lesion in the brain takes up space or the amount of cerebrospinal fluid (CSF) increases, it will also increase brain pressure.

Conditions That Lead to Papilledema

If you have an infection that swells brain tissues or a neoplasm in the brain, it may develop into bilateral papilledema. This swelling can intensify the intracranial pressure. This condition is also called idiopathic intracranial hypertension (IIH) or pseudotumor cerebri. 

IIH replicates the symptoms of a tumor in the brain. Therefore, the patient will present signs of papilledema.

Idiopathic intracranial hypertension is the most common reason for the development of bilateral papilledema. 

ICP may also be related to one of the following:

• Trauma to the head
• A brain abscess, aneurysm, or tumor
• Stroke
• Hydrocephalus
• High blood pressure
• Brain hemorrhaging
• Cerebral edema
• Craniosynostosis
• Meningitis
• Encephalitis
• Cerebral venous thrombosis (CVT)

Some medications may increase your ICP as a side effect. For example, lithium, tetracycline, corticosteroids, nalidixic acid, minocycline, nitroglycerine, nicardipine, or hydralazine can all increase intracranial pressure.

What Causes Unilateral Papilledema?

When papilledema occurs in one eye, it is due to the development of a tumor, known as an optic nerve glioma. Patients often experience headache pain from optic pathway gliomas (OPGs). These are neoplasms that cause unilateral papilledema, and they affect the optic nerve sheath as well.

What Are the Signs of Papilledema?

Papilledema frequently starts with temporary changes in vision. Patients complain that they experience double or blurred vision, total vision loss, or flickering of the vision for small periods of time. Signs that the intracranial pressure has risen include projectile vomiting, nausea, and headache.

A doctor may check for Cushing’s triad, signs that indicate an increase in ICP. These signs include bradycardia (slower heart rate), irregular respiration, or an increased difference between systolic and diastolic blood pressure. Systolic pressure measures blood pressure between heart beats, while diastolic blood pressure measures resting heartbeat.

While the patient often experiences headache pain, with the pain worsening upon waking up or lying down, the condition does not produce eye pain. Severe cases of papilledema lead to decreasing vision, poor color perception, or a limited visual field. 

If the cause for the increased brain pressure is unknown (idiopathic intracranial hypertension or IIH), the signs will still be similar to a brain tumor. IIH will also often co-occur with symptoms of papilledema.

How Is Papilledema Diagnosed?

When making a diagnosis for papilledema, an eye doctor will review your medical history and vital signs, and ask about symptoms. They use this information to rule out other optic nerve disorders.

Tests Used to Diagnose Papilledema 

Several tests may be used to determine if a patient has papilledema. These include the following:

• Funduscopic examination
• Perimetry test
• Fluorescein angiography
• B-scan ultrasonography
• Optic coherence tomography
• Computed tomography (CT) scan
• Spinal tap
• Magnetic resonance imaging (MRI)
• Magnetic resonance venography

Checking the Severity of the Disease

The above tests allow the doctor to check for swelling of the optic nerve and determine a cause. If the doctor diagnoses papilledema, he’ll use a Frisén scale to determine the severity. The scale checks optic disc swelling in grades ranging from 0 to 5.

Risk Factors for Papilledema

Any risk factor for papilledema represents an event that raises ICP. Therefore, the risk is increased if a tumor is present or a lesion occupies the intracranial space, such as a subarachnoid hemorrhage. 

Subarachnoid Hemorrhage or Bleeding in the Brain

A subarachnoid hemorrhage often results from a brain aneurysm, and it leads to bleeding in the space surrounding the brain. When the blood builds up, so does intracranial pressure.

Cerebrospinal Fluid Levels

The risk also increases for papilledema if the patient’s absorption of cerebrospinal fluid decreases or a change affects the cerebrospinal flow because of an obstruction in the ventricles. In rare cases, increased production of cerebrospinal fluid may lead to development of the condition.

Papilledema & Intracranial Pressure 

If intracranial pressure does not decrease, dangers to a person’s health increase. For instance, if ICP rises, the patient may experience a brain hemorrhage, which may lead to papilledema and an aneurysm or stroke.

If a brain abscess increases ICP, the patient may not only develop papilledema but also thrombosis, septicemia, or meningitis. 

If the papilledema or underlying cause for the condition are not treated immediately, an increase in intracranial hypertension will also affect the optic nerve, leading to permanent damage. This, in turn, can lead to vision loss. 

At-Home Remedies to Reduce ICP

To reduce intracranial pressure at home, avoid activities that increase it, such as climbing, pushing items, coughing, or sneezing, as much as possible. It is also helpful to reduce anxiety and stress. If you smoke, you should quit as soon as you can. A doctor can help you devise a plan to do so. 

When lying down, keep your head elevated by using a wedge pillow or position your pillows so they slope. Do not lie flat. You can also raise your bed about 30 degrees to reduce intracranial pressure. You can do this by placing blocks under the head of the bed.

You’ll also need to review your blood pressure regularly and make sure your blood sugar levels are healthy too.

Treatment Options for Papilledema

For treatment, consult with an ophthalmologist, neurosurgeon, and neurologist. Their goal, through treatment, will be to reduce swelling of the optic disc and treat the increased intracranial pressure.

Medications for Controlling ICP

Medications prescribed for controlling ICP may include the following:

• Antibiotics to treat cranial infection
• Anticoagulants to dissolve blood clotting
• Pain relievers for reducing headache pain
• Corticosteroids to reduce swelling
• Diuretics for reducing cerebral pressure
• Carbonic anhydrase inhibitors to decrease the production of cerebrospinal fluid (CSF)
• Topiramate (also called Topamax) to relieve migraines and decrease ICP 

To determine the cause of ICP, specialists check the circulation and absorption rate.

Surgery

To reduce intracranial pressure, your doctor may recommend one of various procedures, such as the following:

• A brain shunt to redirect the flow CSF
• Decompression of the optic nerve sheath to relieve swelling of the optic disc and improve the vision 
• A spinal tap or lumbar puncture, which reduces cerebrospinal fluid

If you have been diagnosed with IIH and obesity is considered a risk factor, a doctor may suggest bariatric surgery to treat obesity.

If your ICP is caused by a tumor, abscess, or subdural hematoma in the brain, a surgeon may recommend a burr hole procedure or craniotomy. During a craniotomy, the surgeon temporarily takes out part of the skull and excises the tumor, subdural hematoma, or abscess. When burr hole surgery is performed, the doctor creates a hole in the skull before inserting a tube to drain the hematoma, or the blood that has collected from a head injury.

See a Doctor Promptly

Papilledema can do significant damage to the optic nerve. It can also lead to a loss of vision and even death. 

If you experience a trauma to the head or have a health condition that affects your cerebrospinal fluid production, see a doctor immediately to mitigate the potential for long-term damage.

References

1. Papilledema. Genetic and Rare Diseases Information Center.

2. Etiology of Papilledema in Patients in the Eye Clinic Setting. (June 2020). JAMA.

3. Optic Nerve Glioma. (May 2022). StatPearls.

4. Cushings Reflex and Triad. (February 2023). Department of Emergency Medicine, University of Maryland School of Medicine.

5. Chapter 17: Fundoscopic Examination. Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edition.

6. Rating Papilloedema: An Evaluation of the Frisén Classification in Idiopathic Intracranial Hypertension. (July 2012). Journal of Neurology.

7. Papilledema. (April 2021). EyeWiki, American Academy of Ophthalmology.

8. A New Look at Cerebrospinal Fluid Circulation. (May 2014). Fluids and Barriers of the CNS.

9. Subdural Haematoma. (August 2021). National Health Service.

10. Subdural Abscess Following Chronic Subdural Hematoma. (July 1995). No Shinkei Geka.

11. Papilledema: Epidemiology, Etiology, and Clinical Management. (August 2015). Eye and Brain.

12. Papilledema in a Patient With Intracranial Hypotension. (December 2021). Journal of Neuro-Ophthalmology.

13. Optic Disc Edema and Elevated Intracranial Pressure (ICP): A Comprehensive Review of Papilledema. (May 2022). Cureus.