Understanding papilledema: Insights into its clinical presentation across diverse etiologies

Dear Editor, Idiopathic intracranial hypertension (IIH) is a significant cause of papilledema in most clinical settings.[1] Its incidence is higher in obese women of reproductive age, and the prevalence rates are much higher, reflecting its chronic nature.[2–4] We share our observations from a retrospective study of 97 patients diagnosed with papilledema at our neuro-ophthalmology clinic between January 2021 and June 2023. The aim was to understand the clinical profile, underlying causes, and associated systemic findings in these patients. Clinical Findings IIH emerged as the most common cause (51.6%), followed by cerebral venous sinus thrombosis (CVT) (23.7%), intracranial mass lesions (19.6%), and meningitis (5.15%). Sexual differences were seen in IIH and CVT cases, with 84% of IIH cases being women and 69.5% of CVT cases being men [Table 1]. Diplopia (39.2%) was the most frequent presenting complaint. Cranial nerve palsies were noted in 30.9%, predominantly sixth nerve palsy. Asymmetrical disc edema was observed mainly in IIH and mass lesion cases. Visual field defects and color vision abnormalities were more frequent in patients with mass lesions [Table 2]. Among IIH patients, the median BMI was 31.45, and 38% had anemia, hypothyroidism, or menstrual irregularities, suggesting the role of metabolic and hormonal factors in disease pathogenesis.Table 1: Etiology-wise categorization of papilledema cases and sex distribution across the etiologiesTable 2: Neuroophthalmic findings across various etiologies of papilledemaDiscussion Our findings reaffirm that while IIH is the most prevalent cause of papilledema, nearly half of the patients had secondary etiologies. This emphasizes the need for a high index of suspicion for other causes, especially in the absence of typical IIH risk factors. The presence of diplopia and cranial nerve palsies may be early neuro-ophthalmic indicators. At the same time, the nature of visual impairment, such as field and color vision defects, may offer diagnostic clues. Asymmetry in disc edema, previously considered to be rare in papilledema, was a notable finding, especially in IIH [Fig. 1a and b] and mass lesions.Figure 1: (a and b) Asymmetric disc edema in a patient with IIH. The right and left fundus pictures are shown as a and b, respectivelyCVT is a major cause of papilledema, presenting with blurred vision and rapid degeneration of sight.[5,6] A total of 52.2% of our patients with CVT reported a history of impaired vision. Papilledema caused by mass lesions often exhibits distinct features such as visual field defects, color vision abnormalities, and a higher rate of cranial nerve involvement. The increased occurrence of cranial nerve palsies, at 47.4%, and enlarged blind spots in visual fields (31.6%) align with raised intracranial pressure due to mass effect, consistent with the Monro-Kellie doctrine. Systemic factors such as elevated BMI and hormonal imbalances (e.g., hypothyroidism and menstrual irregularities) were significantly associated with IIH, supporting their contributory role in disease pathogenesis. Conclusion Our study highlights the broad clinical spectrum of papilledema and reinforces the importance of a structured diagnostic approach. While IIH remains a common cause, secondary etiologies such as CVT, masses, and infections are not uncommon. A comprehensive clinical, systemic, and radiological evaluation is critical to identify the underlying cause, enabling timely intervention and prevention of visual morbidity. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.