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Bilateral optic disc drusen mimicking papilloedema
  1. Eleftherios I Agorogiannis,
  2. Jonathan M Durnian
  1. St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
  1. Correspondence to Dr Eleftherios I Agorogiannis, St Paul’s Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK; eleftherios.agorogiannis{at}gmail.com

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A young adult male was referred by his optometrist for suspected papilloedema. He complained of a 4-week history of intermittent headache and a 2-day history of blurred vision in his right eye. There were no postural variation in symptom intensity, pulsatile tinnitus or additional neurological symptoms. A recent CT scan of the head (arranged by his general practitioner) had shown no intracranial space-occupying lesions. On examination, Snellen visual acuities were 20/30 on the right and 20/20 on the left. There was no relative afferent pupillary defect, and examinations of colour vision, cranial nerve and anterior ocular segments were normal. Funduscopy showed bilateral optic nerve head elevation with blurred margins (figure 1A,B), and surface and peripapillary haemorrhages around the right optic disc (figure 1A). Red-free photographs showed optic disc autofluorescence (figure 2A,B, arrows), suggesting the presence of optic disc drusen. In addition, fundus angiography showed no fluorescein leakage in either optic disc (figure 2C,D), further disproving the possibility of frank optic disc swelling. Careful examination of orbital CT sections revealed high densities at the insertions of both optic nerves to the globes (figure 3, arrows), corroborating the diagnosis of optic disc drusen. Lumbar puncture showed normal cerebrospinal fluid opening pressure and composition. We gave no treatment, and 10 months later his headache and visual symptoms had resolved, and the optic discs still looked raised with no haemorrhages.

Figure 1

(A,B) Elevated appearance and blurred margins of optic discs caused by drusen.

Figure 2

(A,B) Optic nerve head autofluorescence (arrows) characteristic of drusen. (C,D) Late-phase fluorescein angiograms showing normal pattern of staining in both optic nerve heads and the absence of any peripapillary choroidal neovascular membranes.

Figure 3

Increased signals on CT (arrows) generated by the presence of calcified optic disc drusen.

Optic disc drusen (prevalence of 2%) usually manifest as bilateral calcified nodules within the optic nerve head, producing a lumpy optic disc appearance.1 They are asymptomatic but can be complicated by haemorrhages, peripapillary neovascular membranes, anterior ischaemic optic neuropathy and visual field loss.1 2 They are frequently mistaken for papilloedema (bilateral optic disc swelling secondary to increased intracranial pressure) and so are referred to as pseudopapilloedema. Physicians need to consider drusen in their diagnostic approach to suspected papilloedema, but also be aware of the possibility of a ‘double’ diagnosis. Accordingly, all patients with symptoms suspicious for raised intracranial pressure require brain imaging. Autofluorescence imaging and ultrasonography can aid in differential diagnosis in order to minimise unnecessary treatment.

Key points

  • Optic disc drusen are usually identified as incidental findings on routine funduscopy of asymptomatic patients.

  • Optic disc drusen complications, like peripapillary haemorrhages, can manifest with visual symptoms and produce ambiguous clinical pictures resembling optic disc swelling.

  • Optic disc drusen occur in 2% of the general population, giving a definite possibility of a compound diagnosis; clinicians should carefully correlate the patient’s symptoms and clinical signs in order not to miss important diagnoses, such as concurrent raised intracranial pressure.

References

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Footnotes

  • Contributors Both authors contributed to clinical care of the patient, wrote and reviewed the manuscript and approved its final version.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Mark Lawden, Leicester, UK.

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    Phil E M Smith Geraint N Fuller