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A 16-year-old girl with bilateral optic disc swelling
Digital Journal of Ophthalmology 2011
Volume 17, Number 1
March 12, 2011
DOI: 10.5693/djo.03.2011.02.003
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Usman Mahmood, MB BS, MRCS Ed | Wolverhampton and Midland Counties Eye Infirmary
Syed M Asad Ali, MB BS, MRCS Ed | New Cross Hospital
Mohammad Samir Dowlut, MB ChB | New Cross Hospital
Bala Manoj, FRCS, MRCOphth, MS, DO | New Cross Hospital
Differential Diagnosis
Bilateral optic disc swelling can result from a variety of inflammatory, infectious, toxic, metabolic, genetic, or vascular conditions, including hypertension.(2)

In hypertensive optic neuropathy, the mechanism of disc swelling is controversial, but ischemia of the optic nerve head is thought to play a role.(3) However, it is usually unilateral or, if bilateral, is frequently associated with other signs of hypertensive retinopathy, such as retinal hemorrhages and exudates and cotton wool spots. There can also be signs of hypertensive choroidopathy with exudative retinal detachments.(4)

Optic nerve head drusen can cause bilateral optic disc swelling, but spontaneous venous pulsation is present in about 80% of patients, and it is not associated with headaches. B-scan of the optic discs is usually diagnostic, but a lack of calcification in children and adolescents can sometimes render this investigation unreliable. In such cases the optic discs have a pink appearance, and the edges are rarely completely obscured.

Idiopathic intracranial hypertension can cause papilledema with associated headaches. It usually affects young, overweight women. Patients frequently report worsening of the headaches with activities that increase intracranial pressure, such coughing or sneezing. They can have visual obscuration, tinnitus, and auditory sensations. CT scan may be normal, although there may be small or slitlike ventricles and an “empty sella sign.” Cerebrospinal fluid pressure is raised on lumbar puncture.

An intracranial space-occupying lesion will usually be detectable on head CT or will be associated with evidence of hydrocephalus. Hypertension is not a feature of these conditions.