A 22-year-old woman is referred urgently with ‘bilateral papilloedema’ found at a routine optometrist visit. She does have headaches, which frightened her further. But the headaches are infrequent, there are no transient visual obscurations, no vomiting, no diplopia — and her vision is 6/6 with full fields.
Examination Findings
Both optic discs are elevated with lumpy, irregular margins and refractile glistening deposits on the disc surface — but the vessels are not engorged, there is no obscuration of vessels at the margin, and no haemorrhages. Vision 6/6, colour vision normal, no RAPD, fields full. B-scan ultrasound shows highly reflective calcified deposits within the discs. Fundus autofluorescence highlights the deposits.
Investigations
B-scan ultrasound is the key bedside test — drusen calcify and reflect brightly. Fundus autofluorescence confirms. OCT of the nerve fibre layer sets a baseline, since drusen can cause slowly progressive field defects. Neuroimaging is reserved for atypical cases; here the picture is classic.
Questions to Think About
- Which disc features argue against true papilloedema?
- Why does the B-scan settle it?
- Why does she still need follow-up if this is benign?
Diagnosis
Bilateral optic disc drusen causing pseudopapilloedema.
Reasoning
Reasoning: True papilloedema from raised intracranial pressure shows venous engorgement, vessel obscuration at the disc margin, haemorrhages and cotton-wool spots, with symptoms of raised pressure — none of which are present. Instead the discs are lumpy with glistening refractile bodies, normal vessels and no haemorrhages: buried optic disc drusen, calcified deposits that elevate the disc and mimic swelling, common in young people. The B-scan proves it by showing the calcification directly. Diagnosis: bilateral optic disc drusen (pseudopapilloedema). Management: typical management includes reassurance — no lumbar puncture, no intracranial pressure treatment — with baseline fields and OCT and periodic review, because drusen can slowly compress nerve fibres and cause progressive field defects over years, and can rarely precipitate vascular events at the disc. She is told her headaches are a separate issue to pursue with her doctor, but her ‘papilloedema’ is an anatomical variant, not raised brain pressure.
Differential Diagnosis
- True papilloedema — ruled out: no venous engorgement, no haemorrhages, no obscurations, normal fields, calcification on B-scan.
- Diabetic papillopathy — ruled out: not diabetic, and drusen are visible.
- Optic neuritis — ruled out: painless, bilateral disc elevation, normal colour vision, no RAPD.
Management
Typical management includes confirmation (B-scan/autofluorescence), reassurance, baseline visual fields and OCT, and long-term periodic review for slowly progressive field loss. No pressure-lowering or neurological treatment is indicated. If field defects progress significantly, low-vision and occupational advice follows. Family members may be offered examination, as drusen can run in families.
Key Learning Points
- Drusen mimic papilloedema: lumpy glistening elevation without venous engorgement or haemorrhages.
- B-scan showing calcification is the bedside proof.
- Pseudopapilloedema needs no lumbar puncture — but it does need follow-up for slowly progressive field defects.
- Symptoms matter: no obscurations, no diplopia, normal vision argues against raised pressure.
Red Flags
- Assuming every swollen-looking disc is raised intracranial pressure — check vessels, haemorrhages and symptoms first.
- New haemorrhage or sudden field loss on drusen — vascular complication at the disc; urgent review.
- Headaches plus disc elevation — still exclude raised pressure when the picture is not classic for drusen.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.