Symptoms of papilledema, different manifestations in 4 stages

The occurrence of optic disc edema is not uncommon in life. The symptoms of this disease are not the same in the four stages: early stage, progressive stage, malignant stage, and terminal stage. During treatment, a plan must be formulated according to different symptoms.

1. Early type: Its pathological changes are based on nerve fiber swelling, extracellular fluid accumulation and optic disc vascular dilation. Examination of the fundus using color stereo fundus photography and a stereo ophthalmoscope can reveal swelling and turbidity of the nerve fiber layer around the optic disc, and the loss or bending of the straight white reflective stripes. The colors become darker and blurry. Optic disc congestion or superficial hemorrhage is caused by dilation or rupture of microvessels on the surface of the optic disc. Generally, funduscopy can often distinguish the disease, and it is best to use contact lenses combined with slit lamp examination, which is extremely valuable in diagnosing this type. The blurring of the optic disc edge usually starts from the bottom to the top of the optic disc, then extends to the nasal edge, and finally becomes blurred on the temporal side. This is because the density of the nerve fiber layer in different parts of the optic disc is different, and the denser areas swell earlier. The presence or absence of spontaneous retinal vein pulsation is of certain significance in determining this type. However, 12% to 20% of normal people may have no venous pulsation. At the same time, increased intracranial pressure often fluctuates. For example, if the venous pulsation is observed between two peak fluctuations of increased intracranial pressure, the intracranial pressure will drop below 26.7 kPa (200 mmHg) and the retinal venous pulsation may reappear, which may even lead to misdiagnosis. Therefore, the exact meaning is still controversial, but the observation is convenient and easy to perform and still makes sense as a reference indicator. Fundus fluorescein angiography can show fluorescence leakage in the optic disc's small blood vessels and arteriolar formation, and even leakage around the optic disc, which is caused by increased capillary permeability. It becomes strongly fluorescent in the later stage. Detecting the enlarged characteristic of the physiological blind spot is the horizontal diameter which aids in diagnosis. This type cannot be diagnosed based on a single body weight but must rely on a comprehensive analysis of several physical signs, and suspected cases should be followed up.

2. Ongoing type

The surface of the optic disc is obviously raised, up to 3 to 4D, and mushroom-shaped. The tiny hemangiomas and capillary dilations on the surface of the optic disc are very obvious, punctate or flame-like hemorrhages can be seen around the disc, the disc edge is significantly blurred, and the veins passing through the edge are dilated and tortuous, which may be intermittent. If the intracranial pressure rises rapidly, large flame-shaped hemorrhages, cotton-like exudates, and even subvitreal hemorrhage may be seen. Hard protrusions and hemorrhages may also be seen in the macula. In severe cases, Paton's lines may be seen, mostly occurring on the temporal side of the optic disc and in a semi-arc shape. This is because the optic disc tissue swells, pushing and shifting the retina at the temporal edge, causing wrinkles in the retina folds and varying degrees of reflection on the inner edge of the retina. If optic disc edema persists, new blood vessels may be seen under the retina around the disc.

3. Malignant stage

This type differs from the progressive type only in degree. For example, when intracranial pressure rises sharply and suddenly, the optic disc tissue and retinal blood vessels cannot adapt, and a large amount of flake bleeding and exudate occur. The optic disc edema and protrusion can be as high as 5 diopters (D) or more, but there are also patients without bleeding and exudate. Visual acuity is often impaired to some extent, and the visual field may shrink centripetally (excluding the characteristic visual field of encephalopathy).

4. Terminal type

Also called atrophic type. Regardless of the type, patients with optic disc edema that does not subside for a long time may develop into this type. The optic disc becomes rounded and slightly elevated, the white cup-shaped depression in the center of the disc disappears, the color of the optic disc changes from red to grayish white, the arteries become thinner, the veins are slightly thicker or normal, the retinal blood vessels are sheathed, the retinal edema around the disc is absorbed, and small round, smooth, shiny, hard exudates are sometimes seen in the surface tissue of the optic disc, which look like warts buried under the surface tissue of the optic disc. This type of disease includes decreased vision, color vision impairment, and visual field loss. If intracranial decompression is performed, there is a risk of sudden or gradual loss of vision.