From the Guidelines
The management of papilloedema should prioritize reducing intracranial pressure through weight loss, medication, and surgical interventions, with a focus on protecting vision and minimizing headache morbidity, as recommended by the 2018 consensus guidelines on idiopathic intracranial hypertension management 1.
Key Principles of Management
- Treat the underlying disease
- Protect the vision
- Minimize headache morbidity
Initial Assessment and Treatment
Initial assessment should include a thorough neurological examination, neuroimaging (preferably MRI with venography), and lumbar puncture if safe to perform. For idiopathic intracranial hypertension (IIH), weight loss of 5-10% is recommended for overweight patients. First-line medication therapy includes acetazolamide starting at 500mg twice daily, gradually increasing to 1-2g daily in divided doses as tolerated, with common side effects including paresthesias, fatigue, and altered taste 1.
Monitoring and Follow-up
Regular ophthalmologic monitoring with visual field testing and optical coherence tomography is essential to track disease progression and treatment response. Any patient with papilloedema should have the following documented: visual acuity, pupil examination, formal visual field assessment, dilated fundal examination to grade the papilloedema, and BMI calculation 1.
Surgical Interventions
For severe or progressive visual loss despite medical therapy, surgical interventions should be considered, including optic nerve sheath fenestration to protect vision or CSF diversion procedures (ventriculoperitoneal or lumboperitoneal shunting) to reduce intracranial pressure. Note that evidence from 1 is not directly applicable to the management of papilloedema in the context of this question, as it pertains to a different patient population and treatment scenario.
From the Research
Management of Papilloedema
The management of papilloedema typically involves addressing the underlying cause of increased intracranial pressure (ICP) [ 2, 3, 4 ].
- Weight loss and medical therapy, such as acetazolamide or furosemide, are often the initial treatments for idiopathic intracranial hypertension (IIH) [ 2, 3 ].
- For patients who fail or are intolerant to medical therapy, surgical options such as optic nerve sheath fenestration or cerebrospinal fluid diversion procedures may be considered [ 2, 3 ].
- Ventriculoperitoneal shunting is also a common surgical procedure for patients with IIH who do not respond to medical treatment [ 4 ].
Diagnostic Approach
The diagnostic approach to papilloedema involves measuring blood pressure, ruling out pseudopapilledema, and performing magnetic resonance imaging (MRI) of the brain and orbits with venography sequences [ 4 ].
- Lumbar puncture with measurement of opening pressure and evaluation of cerebrospinal fluid (CSF) composition is also an important diagnostic step [ 4 ].
- Further investigations, such as MRI of the neck and spine, magnetic resonance angiography of the brain, and computed tomography of the chest, may be necessary to identify underlying causes of increased ICP [ 4 ].
Intracranial Pressure Monitoring
Intracranial pressure monitoring can help identify a pathological threshold for the development of papilloedema [ 5 ].