Stagnant optic disc

Stagnant disc of the optic nerve is non-inflammatory edema, which is a sign of increased intracranial pressure.

A congestive disc is an edema of the optic disc, which develops secondary to increased intracranial pressure. Almost always it is two-sided, although it can be one-sided. All other causes of disk edema in the absence of increased intracranial pressure affect the actual edema and usually cause visual disturbances. In all patients with a congestive disk, intracranial neoplasm should be suspected, until a different reason is proven. However, not all patients with elevated intracranial pressure develop a stagnant disc. Tumors of the hemispheres tend to cause a stagnant disc later than tumors of the posterior cranial fossa. In patients who have had a stagnant disc in the past, intracranial pressure can significantly increase without the re-development of a stagnant disc due to glial scarring of the optic nerve disc.

[1], [2], [3], [4], [5], [6], [7], [8]

What causes a congestive optic disc?

There are many processes that lead to increased intracranial pressure. The first place among them is occupied by intracranial tumors: they are the cause of stagnant disks of optic nerves in 2/3 of cases. Among other less significant causes of increased intracranial pressure, and consequently, the development of congestive optic discs should be called craniocerebral trauma, posttraumatic subdural hematoma, inflammatory lesions of the brain and its membranes, voluminous formations of non-tumor nature, lesions of blood vessels and sinuses of the brain , hydrocephalus, intracranial hypertension of an unknown genesis, a tumor of the spinal cord. The severity of congestive optic discs reflects the degree of increase in intracranial pressure, but does not depend on the volume of volume formation in the cranial cavity. The rate of development of the stagnant disc is mainly due to the localization of the neoplasm with respect to the cerebrospinal fluid system and the venous collectors, in particular, to the sinuses of the brain: the closer the tumor is to the paths of the liquor flow and the sinuses, the faster the developing stagnant optic nerve disk.

Symptoms of congestive optic nerve

A clinically stagnant disc is manifested by its edema, which causes blurring of the pattern and boundaries of the disc, as well as hyperemia of its tissue. As a rule, the process is two-sided, but in rare cases, a stagnant disc can develop only on one eye. Sometimes a one-sided congestive optic disc is combined with disc atrophy and low visual functions on the other eye (Foster-Kennedy symptom).

Edema occurs first along the lower border of the disc, then along the upper, then the nose and temporal half of the disc subsequently swell. Distinguish the initial stage of development of the stagnation disk, the stage of maximum edema and the stage of reverse development of edema.

As the edema builds up, the optic nerve disc begins to enter the vitreous, and the edema spreads to the surrounding peripapillary retina. The disk increases in size, an expansion of the blind spot occurs when the field of vision is examined.

Visual functions can remain normal for a sufficiently long period of time, which is a characteristic symptom of a congestive optic nerve disc and an important differential diagnostic feature. Such patients to the oculist are sent by therapists and neurologists for examination of the fundus in connection with complaints of headache.

Another symptom of a stagnant disc is a sudden short-term sharp deterioration of vision until blindness. This symptom is associated with a transient spasm of arteries feeding the optic nerve. The frequency of occurrence of such seizures depends on several factors, including the severity of the edema of the disk, and can be up to several attacks within 1 hour.

As the stagnant disc develops, the caliber of retinal veins increases, indicating a difficulty in venous outflow. In certain cases, hemorrhages occur, the characteristic localization of which is the area of the disc and the surrounding retina. Hemorrhages may occur with severe swelling of the disc and indicate a significant violation of venous outflow. However, hemorrhages are possible even with an initial or inconspicuous edema. The cause of their development in such cases can be rapid, sometimes lightning, development of intracranial hypertension, for example, with rupture of arterial aneurysm and subarachnoid hemorrhage, as well as with malignant tumor and toxic effects on the vascular wall.

In the stage of developed edema, in addition to the symptoms described above, vaginal whitish foci and minor hemorrhages in the paramacular area against the background of edematous tissue may appear, which can cause a decrease in visual acuity.

A marked decrease in visual acuity is noted in the case of development of an atrophic process in the optic nerve and the transition of the congestive optic nerve disc to a secondary (post-stasis) atrophy of the optic nerve, in which the ophthalmoscopic picture is characterized by a pale disc of the optic nerve with an indistinct pattern and boundaries, without edema or with traces of edema. The veins retain their fullness and tortuosity, the arteries are narrowed. Hemorrhages and whitish foci at this stage of development of the process, as a rule, no longer exist. Like any atrophic process, the secondary atrophy of the optic nerve is accompanied by loss of visual functions. In addition to lowering visual acuity, they detect defects in the field of vision of a different nature that can be caused directly by the intracranial lesion, but more often begin in the lower ninth quadrant.

Since a congestive optic disc is a sign of intracranial hypertension, its timely recognition and differential diagnosis with other similar processes in the eye are very important. First of all, it is necessary to distinguish between the true edema of the optic nerve disk and the pseudo-stasis disc, in which the ophthalmoscopic pattern resembles that of a congestive optic nerve disk, but this pathology is caused by a congenital anomaly of the disc structure, the presence of the drusen disc, often combined with an abnormality of refraction and is detected already in childhood . You can not rely entirely on such a symptom as the presence or absence of a viral pulse, especially in cases of abnormal development of the disc. One of the main symptoms facilitating differential diagnosis is a stable ophthalmoscopic picture in the process of dynamic observation of the patient with a pseudo-stagnant optic nerve disk. Carrying out fluorescent angiography of the fundus also helps to clarify the diagnosis.

However, in some cases, it is very difficult to differentiate the congestive optic nerve disk from diseases such as optic neuritis, the beginning thrombosis of the central vein of the retina, anterior ischemic neuropathy, and meningioma of the optic nerve. With these diseases, there is also edema of the optic disc, but its nature is different. It is caused by pathological processes developing directly in the optic nerve, and is accompanied by a decrease in visual functions of varying degrees of severity.

In some cases, in connection with the difficulties arising in the diagnosis, it is inevitable that the spinal cord is punctured with the measurement of the pressure of the cerebrospinal fluid and the investigation of its composition.

If signs of a congestive optic nerve disc are found, the patient should immediately be referred for consultation to a neurosurgeon or neurologist. To clarify the cause of intracranial hypertension, a computer (CT) or magnetic resonance (MRI) tomography of the brain is performed.

Clinical features of congestive optic nerve

An initial stagnant disc may be difficult to diagnose. Its main features:

• Subjective visual disturbances are absent, visual acuity is normal.
• The discs are hyperemic and a little pronounced.
• The edges of the discs (first the nasal, then the upper, lower and temporal) appear to be indistinct, the parapapillary edema of the nerve fiber layer of the retina develops.
• Disappearance of spontaneous venous pulse. However, in 20% of healthy people the spontaneous venous pulse is not expressed, so its absence does not necessarily imply an increased intracranial pressure. The stored venous pulsation makes the diagnosis of a stagnant disc unlikely.

Developed stagnant disk

• Transient visual disturbances can appear in one or both eyes, often on rising, and last for several seconds.
• Visual acuity is normal or decreased.
• The discs of the optic nerves are highly hyperemic and moderately pronounced, with fuzzy boundaries, at first may appear asymmetric.
• Excavation and small vessels on the disk are invisible.
• Venous congestion, paranapillary hemorrhages in the form of "flame tongues," often reveal vata-like foci.
• As the edema becomes worse, the optic disc looks larger; In the temporal margin, circular folds may appear.
• The deposits of solid exudate can form a "macular fan" divergent from the center of the fovea: an incomplete "figure of the star" with a missing temporal part.
• The blind spot is enlarged.

Chronic stagnant disc

• Visual acuity varies, the field of vision begins to narrow.
• The discs are pronounced as "cork from champagne."
• There are no crooked foci and hemorrhages.
• On the surface of the disc may be opticociliary shunts and drusopodobnye crystal deposits (corpora amylacea).

Atrophic stagnation disk (secondary optical atrophy)

• Visual acuity is sharply reduced.
• Disks are dirty gray, slightly pronounced, with several vessels and fuzzy boundaries.

[9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]

Differential diagnosis of congestive optic nerve

Deep druses can be mistaken for an initial stagnant disc.

Two-sided edema of the disc can be caused:

• Malignant hypertension.
• Two-sided papillitis.
• Two-sided compression endocrine ophthalmopathy.
• Two-sided simultaneous anterior ischemic optic neuropathy.
• Two-sided violation of venous outflow in the central vein of the retina or carotid-cavernous anastomosis.

[20], [21], [22]

Treatment of congestive optic nerve

Treatment for a stagnant disc is directed mainly to the underlying disease, because a stagnant nipple is just a symptom of the disease. With neoplasms in the cranial cavity, a surgical operation is shown - removal of the tumor. Stagnant nipples with meningitis are treated conservatively depending on the underlying disease. Late diagnosis and prolonged existence of a stagnant nipple lead to atrophy of optic nerve fibers.

After eliminating the cause of congestion of the optic nerve discs, if the disc atrophy has not yet developed, the picture of the fundus is normalized in the period from 2-3 weeks to 1-2 months.