From the Guidelines
The workup for bilateral papilledema should begin with urgent neuroimaging, preferably MRI with contrast of the brain and orbits, as recommended by the most recent study 1, to rule out space-occupying lesions, hydrocephalus, or venous sinus thrombosis. This approach is supported by the American College of Radiology, which suggests that MRI of the head and orbits is the most useful imaging modality for initial evaluation of patients presenting with papilledema and signs of raised intracranial pressure 1. The following steps should be taken:
- Urgent neuroimaging, preferably MRI with contrast of the brain and orbits, or CT if MRI is unavailable
- Lumbar puncture to measure opening pressure and analyze cerebrospinal fluid, unless contraindicated by imaging findings suggesting increased intracranial pressure
- Complete ophthalmologic evaluation including visual acuity testing, visual field assessment, and dilated fundus examination
- Laboratory tests should include complete blood count, comprehensive metabolic panel, and inflammatory markers like ESR and CRP
- Additional testing may include MR venography if venous sinus thrombosis is suspected If idiopathic intracranial hypertension is diagnosed, treatment typically involves weight loss if applicable, acetazolamide starting at 500mg twice daily and titrating up to 1000-2000mg daily as tolerated, or topiramate as an alternative, as suggested by the consensus guidelines on management 1. Serial visual field testing is crucial to monitor for progression, and surgical interventions such as optic nerve sheath fenestration or CSF shunting procedures may be necessary for refractory cases or progressive visual loss. Papilledema represents optic disc swelling due to increased intracranial pressure and requires prompt evaluation as it can lead to permanent vision loss if the underlying cause is not addressed quickly. It is essential to note that the management of bilateral papilledema should prioritize the patient's morbidity, mortality, and quality of life, and the treatment approach may vary depending on the underlying cause and individual patient factors, as highlighted in the study 1.
From the Research
Bilateral Papilledema Workup
Bilateral papilledema is a condition characterized by optic nerve head edema secondary to raised intracranial pressure (ICP) 2. The workup for bilateral papilledema involves several steps:
- Measuring blood pressure and ruling out pseudopapilledema 2
- Performing magnetic resonance imaging (MRI) of the brain and orbits with venography sequences to look for indirect imaging signs of increased ICP and to rule out nonidiopathic causes [(2,3)]
- Conducting a lumbar puncture with measurement of opening pressure and evaluation of cerebrospinal fluid (CSF) composition 2
- Assessing for underlying causes of increased ICP, including conditions that decrease CSF outflow or increase CSF production [(2,4,5)]
Diagnostic Considerations
When evaluating bilateral papilledema, it is essential to consider various diagnostic possibilities, including:
- Idiopathic intracranial hypertension (IIH) [(2,4,5)]
- Secondary intracranial hypertension (e.g., cerebral tumor, cerebral thrombophlebitis) 6
- Arteritic ischemic optic neuropathy (or giant cell arteritis) 6
- Non-arteritic ischemic optic neuropathy 6
- Papillitis 6
Imaging Studies
Imaging plays a critical role in the detection of pathologies that can cause papilledema 3. The following imaging studies may be useful: