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Asymmetric Papilledema in Idiopathic Intracranial Hypertension: Prospective Interocular Comparison of Sensory Visual Function

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Asymmetric Papilledema in Idiopathic Intracranial Hypertension: Prospective Interocular Comparison of Sensory Visual Function Asymmetric Papilledema in Idiopathic Intracranial Hypertension: Prospective Interocular Comparison of Sensory Visual Function Michael Wall1'2 and William N. White II13 PURPOSE. Visual loss is the main morbidity of idiopathic intracranial hypertension (UH). The relationship between papilledema grade and visual loss is unclear. The goal of this study was to determine whether there is a relationship between papilledema grade and visual loss. METHODS. Fundus photographs of 478 patients with IIH were reviewed, and their degree of papilledema was graded using Frisen's scheme. We identified 46 patients (10%) with IIH and highly asymmetric papilledema, as defined by an interocular difference of two or more grades. Nine of these patients with active asymmetry agreed to return for a series of visual tests. They underwent three visual field tests—Humphrey visual field analyzer 24-2, motion perimetry, and ring perimetry. The perimetry outcome measures were mean deviation, foveal threshold, and means for eccentric zones (3°, 9°, 15°, and 21°). The patients participated also in visual acuity, Farnsworth-Munsell 100-hue, Pelli-Robson contrast sensitivity, and foveal flicker fusion testing. Their relative afferent pupillary defect was graded using neutral density filters. RESULTS. The intereye comparisons showed vision to be worse in the eye with the high-grade papilledema for all outcome measures. The magnitude of the loss with the perimetry tests increased with eccentricity. The measures of central visual function, although in the normal range, were relatively depressed in the eye with high-grade papilledema. CONCLUSIONS. Visual loss in patients with asymmetric papilledema caused by IIH was most pro- nounced in the eye with the higher grade of papilledema. Foveal visual functions, although they remained in the normal range, were also decreased in patients with high-grade papilledema. In patients with high-grade papilledema, visual loss appeared to affect the entire visual field, and the peripheral field showed the most deficit. Our findings showed that high-grade papilledema was associated with visual dysfunction in patients with IIH. (Invest Ophthalmol Vis Set. 1998;39: 134-142) diopathic intracranial hypertension (IIH) is a disorder of selective loss of either magnocellular or parvocellular func- elevated intracranial pressure of unknown cause. Visual tions. To accomplish this we analyzed sensory visual function Iloss caused by papilledema is the most important compli- data from patients with highly asymmetric papilledema. Our cation of IIH. Patients at risk for permanent visual loss include premise was: If there was no difference in visual function those with severe or high-grade papilledema.1"3 Those with between the two eyes with highly asymmetric papilledema, moderate or less severe papilledema, however, also demon- then there was no relationship between visual loss and papill- strate visual loss using sensitive psychophysical testing tech- edema grade. However, if visual functions were systematically niques.4'5 Rush reported no correlation between papilledema worse in the eye with high-grade papilledema, then the grade and degree of visual loss.6 Others have reported an amount of visual loss was related to the degree of papilledema. association between higher grades of papilledema and more We retrospectively identified patients with highly asymmetric severe visual dysfunction.1"3 papilledema and analyzed their visual functions. We then pro- Our main goal in this study was to investigate the ques- spectively tested nine patients with highly asymmetric papill- tion: Is the amount of visual loss related to the degree of edema with a battery of sensor)' visual function tests. papilledema? Our secondary goal was to look for evidence of SUBJECTS AND METHODS From the Departments of 'Ophthalmology and 2Neurology, Col- We reviewed the optic disc photography files and charts of 478 lege of Medicine, University of Iowa, Iowa City, Iowa, and 'University patients with the diagnosis of IIH evaluated at the University of Eye Specialists, Warsaw, New York. Iowa Neuro-ophthalmology Clinic from 1972 to 1995. Patients Supported by a VA Merit Review Grant and by an unrestricted were excluded if they failed to meet the five modified Dandy grant to the Department of Ophthalmology from Research to Prevent 4 Blindness, New York, New York. criteria for idiopathic intracranial hypertension : there was Submitted for publication May 23, 1997; revised July 23, 1997; presence of signs and symptoms of increased intracranial pres- accepted September 19, 1997. sure; the patient was alert and oriented; the neurologic exam- Proprietary interest category: N. ination was normal except for papilledema and its associated Reprint requests: Michael Wall, Department of Neurology, College of Medicine, University of Iowa, 200 Hawkins Drive, 2007 RCP, Iowa visual loss and sixth nerve palsies; neurodiagnostic studies City, 1A 52242-1053. were normal except for increased cerebrospinal fluid pressure; Investigative Ophthalmology & Visual Science, January 1998, Vol. 39, No. 1 134 Copyright © Association for Research in Vision and Ophthalmology Downloaded from iovs.arvojournals.org on 09/25/2021 IOVS, January 1998, Vol. 39, No. 1 Asymptomatic Papilledema in DH 135 and there was no secondary cause of intracranial hypertension 36 -I found. Initial Visit - High Grade The IIH patients all had fundus photography, and each 34 - Initial Visit - Low Grade patient's papilledema was graded according to Frisen's Final Visit - High Grade scheme.7 Grade 0 defines an optic disc without swelling; Grade 9 32 -I Final Visit - Low Grade 5 represents severe papilledema. Nine patients from these 38 that still had asymmetry of two or more grades present agreed ^ 30 ^ to take part in the study. All participants were reimbursed for their time and travel. The mean patient age was 318 ± 92 2 28 years. I 26 The protocol was approved by the University of Iowa Investigational Review Board and fulfilled the tenets of the 24 - Declaration of Helsinki. Normal subjects for the perimetry tests were randomly chosen from our database of normal control 22 subjects and matched to the patients by age (two control 0 5 10 15 20 25 subjects to each patient). All normal subjects had a normal neuro-ophthalmologic examination and no history of eye dis- Degrees from Fixation ease except refractive error and normal automated perimetry FIGURE 1. Retrospectively collected data on the threshold- results (Program 24-2, Humphrey Field Analyzer; Hvimphrey automated perimetry of 12 patients with highly asymmetric Instruments, San Leandro, CA). papilledema. Note the generalized depression of the visual field The subjects were tested for the following: visual acuity from the fovea to the periphery. Improvement occurred in using the Early Treatment of Diabetic Retinopathy Study chart, both the high-grade and low-grade eyes with treatment. foveal flicker fusion,8 Pelli-Robson contrast sensitivity, relative afferent pupillary defect quantitation using neutral density fil- ters, Farnsworth-Munsell color, and three types of perimetry. targets are circular random dot cinematograms within which We used conventional automated perimetry with the Hum- 50% of the dots move in one of four directions relative to phrey visual field analyzer 24-2, high-pass resolution perimetry fixation (up, down, left, or right) and 50% move in random (Frisen's ring test),9'10 and motion perimetry11. directions.14 The stimulus presentation time was 128 msec. The targets were of 20 different sizes. The angle subtended by Conventional Automated Perimetry the targets ranged from 0.25° to 21°. Using the Humphrey visual field analyzer, and following the The size of the stimulus window varied from trial to trial, manufacturer's recommendations, we performed conventional and a 2 to 1 staircase procedure was used to bracket the automated perimetry. The patients' appropriate near correc- threshold. The test, therefore, continued until the smallest tion was used. Subjects were tested with a program using a circle size seen (size threshold) at each test point was brack- 6°-spaced grid of the central 21°. Rest periods were given eted by the staircase procedure. We tested 44 locations. These when requested. matched the 24-2 Humphrey perimetry test points, except for the absence of the top and bottom rows (y = 21° and —21°) High-Pass Resolution Perimetry and the two points along the nasal horizontal (x = —27°)- The test time for the 44-test loci was approximately 15 minutes. High-pass resolution perimetry was administered according to The perimetry measures were analyzed by calculating the the recommendations of the manufacturer (Ophthimus system; mean score for the ring test and motion perimetry and tabu- HighTech Vision, Goteborg, Sweden) except that, inadver- 2 lating the mean deviation for conventional automated perime- tently, we calibrated the background to 100 cd/m brighter try and by compacting the data for the three tests into concen- than the standard level. Therefore, we will only report differ- tric zones.1015 We excluded the region of the blind spot and ences between the eyes with this test. The patients' appropri- the adjacent-test locations for this analysis so that visual loss ate near correction was used and care was taken to prevent from elevation of peripapillary retina would be minimized. lens rim artifact. Patients' fixation was monitored by the visual The patient's best-corrected visual acuity was recorded field technician and with intermittent blind
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