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Augenheilkunde up2date 2017; 7(02): 127-148
DOI: 10.1055/s-0042-122495
Kinder- und Neuroophthalmologie, Strabismus
Georg Thieme Verlag KG Stuttgart · New York

Die randunscharfe Papille: eine diagnostische Herausforderung

Julia Biermann
,
Wolf Alexander Lagrèze
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Publikationsverlauf

Publikationsdatum:
12. Mai 2017 (online)

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Zusammenfassung

Die Differenzialdiagnosen bei Papillenrandunschärfe sind zahlreich. Harmlose Ursachen und Normvarianten müssen von pathologischen Ursachen abgegrenzt werden. Die Papillenschwellung und insbesondere die Stauungspapille erfordern zeitnah weitere Diagnostik und Therapie.

Abstract

Correct differential diagnosis in cases of blurred optic disc margins is a challenging task for ophthalmologists. The reliable differentiation of pseudopapilloedema and true papilloedema has significant implications for proper patient management. Conditions that give rise to pseudopapilloedema include small crowded discs, tilted discs and optic nerve head drusen. Conditions that cause bilateral true swelling of the optic nerve head with initially good visual acuity include those that are secondary to raised intracranial pressure (optic disc edema, ODE). The majority of cases, however, present with unilateral optic nerve head swelling and normal intracranial pressure. They have systemic signs or symptoms which either precede ocular manifestation or have ophthalmoscopic signs other than elevation of the optic disc pointing to its diagnosis. Ancillary testing has been utilized to aid in identification of true ODE or swelling, including ultrasonography, fluorescein angiography, cranial and orbital MRI with venography, and lumbar puncture. Optical coherence tomography is also evolving as a modality for differentiation of buried optic disc drusen from ODE. This presentation will discuss each modality, with examples, advantages, and disadvantages for each.

Kernaussagen

  • Die Papillengröße sollte bei randunscharfen Papillen initial bewertet werden; eine fehlende oder kleine Exkavation deutet auf eine kleine Papillenfläche hin.

  • Die sichere Differenzierung zwischen einer beginnenden Stauungspapille, einer Papille mit tiefen Drusen und einer Pseudopapillenschwellung ist zum einen durch die ähnliche Erscheinung der Papille mit dem Fehlen von pathognomonischen Zeichen, zum anderen über die in den Frühstadien fehlende Funktionsminderung erschwert.

  • Schwierig zu diagnostizieren sind tiefe, nicht kalzifizierte Drusen, wie sie bei Kindern häufiger vorkommen. Die Fluoreszenz-Angiografie und das Papillen-OCT sind nicht immer hilfreich, jedoch der Sonografie und Fundusautofluoreszenz überlegen.

  • Die trennschärfsten Kriterien, um funduskopisch zwischen einer echten Stauungspapille und einer Pseudopapillenschwellung zu unterscheiden, sind eine peripapilläre Nervenfaserschwellung mit Verschattung der prälaminaren Gefäße sowie das Vorliegen peripapillärer Netzhautfalten.

  • Bis zum 18. Lebensjahr wird ein Liquoröffnungsdruck ab 28 cm H2O als pathologisch angesehen. Sedativa, ein erhöhter BMI und Mängel bei der Messmethodik können das Ergebnis verfälschen.

  • Bei eingeschränkter Sehfunktion ist allen voran an eine Papillenschwellung zu denken, der multiple Differenzialdiagnosen zugrunde liegen können. Hier ist eine ausführliche internistische oder neurologische Untersuchung erforderlich.

  • Gefäßauffälligkeiten und Gesichtsfeldausfälle kommen auch bei Papillenanomalien vor.

  • Bei nicht eindeutigen Papillenbefunden ist eine kurzfristige Verlaufskontrolle mit Sehnervdokumentation, einschließlich einer nativen Fundusaufnahme, hilfreich.

Schlüsselwörter

Papillenschwellung - Stauungspapille - Drusenpapille - Diagnostik - Sehnerv

Key words

Optic disc schwelling - papilloedema - pseudopapilloedema - optic disc drusen - optic nerve
 

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