Papilledema and its differential diagnosis

1. Big picture

Papilledema means swelling of the optic disc caused by increased intracranial pressure (ICP). For the neurology exam, the most important point is not only recognizing the swollen disc, but understanding what it means clinically: raised ICP until proven otherwise.

The examiner usually wants you to know:

• papilledema is usually bilateral;

• visual acuity may be normal at the beginning;

• it is a sign of intracranial hypertension, not primarily an eye disease;

• lumbar puncture must not be done before excluding a mass lesion or obstructive hydrocephalus by CT/MRI;

• the main differentials are optic neuritis/papillitis, ischemic optic neuropathy, malignant hypertension, retinal vein occlusion, and pseudopapilledema.