Pseudopapilledema vs. True Papilledema

Ophthalmoscopic  Features of    Pseudopapilledema

• Elevated disc; margins obscured

• Absence of physiologic   cup

• Vascular anomalies with increased branching

• Normal nerve fiber layer; disc transilluminates

• May have spontaneous venous pulse

• May see disc drusen  (“hyaline bodies”)

• Hemorrhages rare

• No exudates

• No nerve fiber layer  infarcts

Pseudopapilledema vs. True Papilledema

J.L. Smith “The Optic Nerve” ~ 1975

Finding                 Pseudo        True

SVP                       Yes            No   

Hemorrhages         No             Yes

Retinal Striae        No              Yes

Enlarged BS                   No              Yes

TVO                     No              Yes

FluoroLeakage      No              Yes

Other Neuro                   No             Yes

High Hypermet      Yes              No

Opthlamoscopic finding of papilloedema        

Frisen Grades of

“Swelling of the Optic Nerve Head”

• Grade 1: C-shaped blurring of nasal,

superior and inferior margins of disc;

temporal margin normal.

• Grade 2: 360-degree elevation of the disc

margin

• Grade 3: Elevation of entire disc with

partial obstruction of one or more of the

retinal vessels at the disc margin

• Grade 4: Complete obliteration of cup and

complete obscuration of at least some of the

vessels on the surface of the disc

• Grade 5: Dome-shaped appearance with all

vessels being obscured (“champagne cork”

papilledema)

Other Signs Consistent With Papilledema

Flame shaped hemorrhages

Paton’s lines

Intraretinal exudates

Intraretinal hemorrhages

Unilateral or Asymmetric Papilledema

In IIH about 10% of cases have asymmetric

Swelling.

Ref: Papilledema vs.Pseudopapilledema

Robert L. Tomsak, MD, PhD Professor of Ophthalmology and Neurology

Wayne State University School of Medicine

Specialist in Neuro-ophthalmology . Kresge Eye Institute .Detroit, MI