FP814 : Analysis of Causes of Papilledema in Pediatric Age Group – 2 Years Rural Hospital Based Study

Group – 2 Years
Rural Hospital Based Study. Dr. Madhumita
Prasad, P19180, Dr. Neha Chandak, Dr. Shashank
Banait, Dr. Sachin Daigavane, Dr. Surabhi Sharma

Analysis of causes of papilloedema in pediatric age group-

2 years rural hospital based study

Dr. Neha Chandak, Dr. Shashank Banait, Dr.Sachin Daigavane, Dr.Surabhi Sharma

 Introduction:

There is perhaps no neuro-ophthalmic sign that is as baleful as papilledema.

Hayreh’s theory states that increased optic nerve tissue pressure causes alteration of pressure gradient across lamina cribrosa which causes blockage of axoplasmic flow from retinal ganglion cells to lateral geniculate body leading to papilloedema.¹

Papilledema if untreated can lead to severe visual impairment and costs a heavy toll on the resources of the child and his family. In already resource constraint population of our area, it may be useful to identify various causes of papilledema in the paediatric age group (0 to 18 years). We therefore decided to identify various causes contributing to development of papilledema, in a rural based tertiary hospital which serves predominantly rural population in and around Wardha District.

Material and Methods:

 This cross-sectional study was carried out from the period of April 2014 to March 2016. 108 children < 18 years of age referred to ophthalmology department of our hospital, having papilledema on fundoscopy,were included. A detailed history including past history of any intrauterine infection was elicited and thorough clinical examination was done in all cases. Neuro imaging (mostly CT scan) was done in all cases. Lumbar puncture & CSF analysis (including the opening pressure of CSF) was done whenever required. Patients were managed medically or surgically as suggested by concerned departments.

Results:

 The mean age of patients was 9.3 + 2.6 years with 65% males & 35% females (age range: 1.5-18 years). More children (51%) were in the age group 7-12 years, followed by 30.5% children aged 13-18 years and 18.5% children aged 0-6 years. (Table 1)

Table 1: Age and gender distribution of patients 

Age group (years)	Number of patients	Percentage (%)	Sex Male       Female
0-6	20	18.5	12	8
7-12	55	51	37	13
13-18	33	30.5	21	12
Total	68	100	70	33

 There was no past history of any significant intrauterine infection in 91.6% patients. Most of the children presented with headache (75.9%), fever (62%) and vomiting (61%).Visual symptoms were present in 13% children. Visual acuity could be determined only in 44.4% cases by Snellen’s chart at presentation as many children were unconscious, uncooperative, non-ambulatory and preschool children (Table 2).

Table 2: Distribution of patients based on the presenting symptom 

Presenting symptoms	Number of patients	Percentage (%)
Headache	82	75.9
Fever	67	62.0
Vomiting	61	56.4
Seizures	16	14.8
Diminution of vision	13	12.0
Ear discharge	11	10.1
Impaired level of consciousness	17	15.7
Focal neurological deficit	8	7.4

The most common cause of papilledema in pediatric age group in our study was found to be infective consisting of 49 cases (45.3%). Tubercular meningitis with obstructive hydrocephalus, occurring as a sequel of tubercular meningitis was the most common infective cause leading to papilledema.The next common etiology was space occupying lesions. Papilledema was most evident with tumours of posterior fossa which obstruct the aqueduct of Sylvius. Other etiologies causing papilledema included otogenic intracranial complications and pseudotumor cerebri (Table 3).

Table 3: Distribution of patients based on the etiology 

Etiology		Number of patients	Percentage (%)
Infective	Tubercular meningitis Viral encephalitis/ meningoencephalitis Bacterial meningitis	31 10   8	28.7 9.2   7.4
Space occupying lesions	Tumors Tuberculoma Hematoma Neurocysticercosis	16 13 6 4	14.8 12.0 5.5 3.7
Otogenic intracranial complications	Abscess Sigmoid sinus thrombosis	9 3	8.3 2.7
Pseudotumurcerebri	Idiopathic	8	7.4

 Infective etiology was the most common cause leading to papilloedema in the 0-6years age group whereas spaceoccupying lesions were commonly seen in 7-12 years age group. On the contrary, cases of different etiologieshad almost similar incidence in the 13-18 years age group. (Table 4)

Table 4: Distribution of patients depending on etiology among

different age groups 

Age group (years)	Infective	Space occupying lesions	Otogenic	Pseudotumorcerebri
0-6	20	3	1	2
7-12	14	22	6	5
13-18	15	14	5	1
Total	49	39	12	8

14 (12.9%) cases died during the study period due to the disease. The mortality was highest in cases with tumors. While 22 children (20.3%) had visual impairment, 13 children (12.03%) had total optic atrophy after resolution of papilledema during the study period (Table 5).

Table 5: Distribution of patients depending on final visual outcome

Visual outcome	0-6 years	7-12 years	13-18 years
Death	4	7	3
Normal visual acuity (BCVA>6/18)	–	10	5
Visual impairment (BCVA<6/18)	–	13	9
Total optic atrophy	2	7	4
Total	6	37	21

Discussion:

The most common etiology of papilledema in our study was found to be tuberculosis, either in the form of infection (tubercular meningitis) or space occupying lesion (tuberculoma) followed by space occupying lesions. Brain damage in tubercular meningitis is the consequence of marked tendency towards granulation, organization and fibrosis of the basal exudates, which causes raised intracranial tension and obstructive hydrocephalus. The most common cause of papilledema at the Children’s Hospital in Philadelphia was brain neoplasm followed by pseudotumor cerebri.² This reflects the high incidence of tuberculosis in our country compared to the developed countries.

Any intracranial tumour may induce papilledema. It is most evident with tumors in the posterior fossa which obstruct the aqueduct of Sylvius, and least with pituitary tumors. The site of the tumors is; thus, more important than its nature, its size and rate of growth. In their study on 200 cases of brain tumours, Wilne et al found that papilledema was present in 38% cases.³

Increased intracranialpressure without a mass lesion (pseudotumorcerebri) is also an importantcause of papilledema.

The lesser frequency of papilledema in infants is consistent with most other studies and reflects the ability of the cranial vault to expand in response to raised intracranial pressure as the cranial sutures have not closed.

Thus, this study has provided insight into the various causes of papilledema in the pediatric age group. Preventive measures to reduce the same can be adopted to prevent visual impairment due to papilledema. Ophthalmological examinations need to be scheduled on a regular basis to follow papilledema, and to determine response to treatment.

References:

• Hayreh, S. S. (1976). Pathogenesis of optic disc oedema in raised intracranial pressure. Transactions of the Ophthal- mological Societies of the United Kingdom, 96, 404-407.
• Grant T. Liu, Nicholas J. Volpe, Steven L. Galetta. Neuro-Ophthalmology: Diagnosis and Management, 212
• S H Wilne, R C Ferris, A Nathwani, C R Kennedy. The presenting features of brain tumours: a review of 200 cases. Archives of Disease in Childhood, 2006;91:502-506