Papilledema (Swollen Optic Nerve)

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What is a Papilledema (Swollen Optic Nerve)?

If you have papilledema, you are experiencing elevated pressure in or around the brain (intracranial pressure). This condition causes swelling of the optic disc. The optic disc is the circular area in the back of the inside of the eye where the optic nerve and retina come together. 

You should know that papilledema is secondary to increased intracranial pressure. In other words, there is an underlying cause that is raising intracranial pressure and thereby affecting the optic disc. 

Some papilledema cases are minor. But others may require immediate, emergency intervention. The underlying cause can also vary from meningitis to tumors to thrombosis.

The time of onset could be weeks if intracranial pressure increases slowly and is mild. On the other hand, the condition can also develop within a few hours to a day. 

Other relevant aspects of this condition include possible vision problems, such as:

  • Intermittent flickers of gray vision 
  • Diplopia (double vision)
  • Blurred vision
  • Decreased field of vision or ability to distinguish among colors

If you believe you have this eye condition, you should visit your local eye clinic and speak with an ophthalmologist. You’ll undergo a comprehensive eye examination and brain imaging studies to rule out other possible causes or health issues. Treatment will be unique to your case and could include medications, surgery, and/or weight management. 

Papilledema is not the same as optic disc edema. The former eye condition occurs because of increased intracranial pressure. Optic disc edema happens due to other causes. 

How Common is a Swollen Optic Nerve?

A swollen optic nerve can arise when you have an underlying condition. Papilledema is not the only eye condition that involves an area of the optic nerve

There are conditions like optic neuritis that can cause swelling of the optic nerve. However, unlike papilledema, the cause of optic neuritis is not clear. Interestingly, an estimated 50% of people with multiple sclerosis will develop optic neuritis. 

One study described how many patients (58 of 86) presented with idiopathic intracranial hypertension as the underlying cause of papilledema (67%).  Previous trauma or a known intracranial mass (22%) were secondary leading causes.2  

Idiopathic intracranial hypertension (high pressure) can cause signs and symptoms similar to those of a brain tumor. 

What Causes Papilledema?

Papilledema is secondary to intracranial pressure. This means that multiple causes of increased pressure are possible.

For example, underlying causes include:

  • Brain tumor or abscess
  • Head injury or trauma
  • Bleeding in the brain (hemorrhage)
  • Inflammation of the brain (encephalitis)
  • Inflammation of tissue linings in the brain, typically caused by infection (meningitis)
  • Inflammation of the middle layer of the brain's coverings (arachnoid adhesions)
  • Blood clot in particular brain veins (dural or cavernous sinus thrombosis)
  • Idiopathic intracranial hypertension (pseudotumor cerebri)
  • Some medications, such as tetracycline, minocycline, lithium, isotretinoin, nalidixic acid, and corticosteroids

Idiopathic intracranial hypertension is a common cause of increased pressure. This diagnosis is made when the intracranial pressure is elevated for no apparent reason (no sign of infection, inflammation, etc). Certain risk factors, such as anemia, thyroid disease, or recent weight gain, could predispose people to this condition. 

What are the Symptoms of Papilledema?

If you have papilledema, you may not have any significant vision issues. However, other symptoms may occur while the course of the condition unfolds, including:

  • Headache
  • Nausea 
  • Vomiting 
  • Blurred vision
  • Double vision 
  • Complete loss of vision 
  • Pulsatile tinnitus (when you hear rhythmic thumping, whooshing, or throbbing in one or both ears)

Papilledema does not cause eye pain, and headache features are often positional and worse in the mornings and when laying down.

Is Papilledema Serious? When is it an Emergency?

If you believe you have papilledema, you should seek medical attention. You may have a mild case of papilledema. However, you may also have an underlying and life-threatening cause of the increased intracranial pressure. 

The following causes could place your life at risk if left untreated:

  • An intracranial mass
  • Obstructive hydrocephalus 
  • Meningitis
  • Cerebral venous sinus thrombosis (CVST)

Similarly, in some cases of papilledema, lack of immediate treatment or care could lead to severe peripheral visual field loss and even decreased central vision

Idiopathic intracranial hypertension does not pose a danger to your life. However, immediate assessment by a health professional may be necessary if you have a severe case of papilledema with an imminent risk of vision loss. 

Potential Complication of Papilledema

When left untreated, papilledema may result in complications and increase your risk of either permanent bodily harm or death.

For instance, chronic papilledema could cause a constriction of the visual field and loss of central acuity (sharpness). 

At the same time, elevated intracranial pressure occurs because of an underlying health issue. If the cause of increased pressure is, for example, meningitis, you could experience complications like:

  • Hearing loss
  • Vision loss
  • Amputation
  • Bone and joint problems 
  • Recurrent seizures 

You should speak with a healthcare professional if you believe you suffer from papilledema or experience any of the symptoms mentioned above. 

Papilledema due to other causes of intracranial hypertension may occur at any age, in either sex, and in any racial or ethnic group. However, idiopathic intracranial hypertension primarily affects women who are obese and of childbearing age. 

How is Papilledema Diagnosed?

A healthcare professional will perform a series of tests to diagnose papilledema and rule out other possible conditions. You may have your blood pressure checked to eliminate the possibility of malignant hypertension (which requires immediate care). 

A vital component of a papilledema diagnosis is high, increased intracranial pressure, and a fundus exam noting optic disc swelling (often in both eyes). Other diagnostic tools include:

  • Ultrasonography 
  • Fluorescein angiography 
  • Fundus autofluorescence 
  • Optical coherence tomography with enhanced depth imaging of the optic nerve head
  • Magnetic resonance imaging (MRI)
  • Computed tomography (CT)

Additionally, healthcare professionals may perform a lumbar puncture (spinal tap) to confirm the diagnosis of high intracranial pressure and evaluate other possible causes. A sample of the cerebrospinal fluid could indicate an infection or a brain tumor.  

They may also use the modified Dandy criteria to rule out idiopathic intracranial hypertension and begin more appropriate and timely treatment. 

How is Papilledema Treated? 

Papilledema will require treatment to address the underlying cause and minimize the risk of vision loss and complications. 

You can break down papilledema management goals into three primary factions:

  • Treatment of the cause of intracranial pressure. This will vary according to the health issue at hand. For example, if you have high pressure caused by a build-up of cerebrospinal fluid due to a brain tumor, you may receive corticosteroids. You may also need to undergo either surgery to take out the tumor or radiation therapy to decrease tumor size. Similarly, if the underlying cause is a bacterial infection, antibiotics could be the most indicated therapy. 
  • Saving vision. Vision loss is a possible and real complication. 
  • Symptomatic relief. Intracranial pressure may cause symptoms to appear, including headaches or vomiting. Healthcare professionals may prescribe pain reliever medications to manage the condition. 

Is it Possible to Cure Papilledema?

Recovery from papilledema will depend on the treatment and management of the underlying cause. Bacterial infections are treatable with antibiotics, especially if the bacteria is a non-multidrug-resistant strain.

Some papilledema cases can be severe and even life-threatening (e.g., meningitis). 

Because of this, you should seek medical care immediately if you have symptoms associated with papilledema. Receiving prompt attention could lower your risk of complications, including vision loss and death.

Resources
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 Rigi, Mohammed, et al. “Papilledema: Epidemiology, Etiology, and Clinical Management.Eye and Brain, U.S. National Library of Medicine.

Crum, Olivia M, et al. “Etiology of Papilledema in Patients in the Eye Clinic Setting.JAMA Network Open, JAMA Network, 2 June 2020.

Garrity, James. “Papilledema - Eye Disorders.Merck Manuals Consumer Version, Merck Manuals.

Optic Nerve Swelling (Papilledema).Harvard Health, 26 Oct. 2018.

Papilledema.EyeWiki, 22 Apr. 2021.

Papilledema.” Genetic and Rare Diseases Information Center, U.S. Department of Health and Human Services.

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