Optic Disc Swelling in Cancer Patients: Etiology and Implications

Abstract

Purpose: To analyze the etiology and implications of optic disc swelling in cancer patients treated at a specialized tertiary cancer center in Jordan.

Methods: This was a retrospective study of all cancer patients who had optic disc swelling between January 2019 and December 2020 at King Hussein Cancer Center (KHCC). Patients' data included age, sex, laterality, visual acuity, and the underlying cause and management for the optic disc swelling.

Results: Optic disc swelling was present in 58 cancer patients (96 eyes), with 38 (65%) having bilateral involvement. Among these, 33 (57%) were female, and 43 (74%) were ≤40 years old. At diagnosis, 58 (63%) eyes had a best-corrected visual acuity (BCVA) better than 0.5, improving to 73 (76%) eyes at the last follow-up. High intracranial pressure (ICP) was the most common primary cause (30 patients/52%), followed by tumor infiltration of the optic nerve (10 patients/17%), optic nerve compression (7 patients/12%), and optic nerve inflammation (5 patients/9%). Four patients had pseudopapilledema. Among the 30 patients with high ICP, CNS tumors were predominant (21 patients/70%), with only 3 having idiopathic intracranial hypertension. Medications, including ATRA (All-Trans Retinoic Acid) and systemic steroids, contributed to increased ICP in six patients (20%). BCVA was less than 0.5 in all eyes (100%) affected by tumor infiltration, optic nerve inflammation, and ischemic optic neuropathy, while only eight eyes (14%) with optic disc swelling due to elevated ICP had a BCVA less than 0.5 (p < 0.0001). Management included steroids (53 patients/91%), acetazolamide (30 patients/52%), chemotherapy (20 patients/34%), radiation therapy (13 patients/22%), frequent lumbar punctures (12 patients/21%), and surgery (28 patients/48%). Visual acuity improved in 40 eyes (42%), with only 4 eyes (4%) experiencing deterioration. At a 12-month median follow-up period, 11 (19%) patients were dead, 10 (10%) eyes had poor vision (BCVA less than 0.1), and 21 (22%) eyes had BCVA 0.5 or better.

Conclusions: Various underlying pathologies can induce optic disc swelling in cancer patients, a grave condition capable of causing vision loss. Notably, tumor infiltration of the optic nerve tends to result in more profound visual impairment compared to papilledema due to elevated ICP. Timely detection is crucial, and immediate symptomatic treatment followed by addressing the underlying cause is essential to prevent irreversible optic nerve damage and vision loss in cancer patients.

Keywords: Jordan; chemotherapy; infiltration; optic disc swelling; papilledema.

Figure 1

PRISMA flow diagram showing the laterality of optic disc swelling (unilateral vs. bilateral) and the distribution of underlying causes for each subgroup.

Figure 2

Fundus photos for optic disc swelling for different underlying diseases. (A,B) Bilateral optic disc swelling secondary to increased intracranial pressure. (C,D) Bilateral optic nerve metastasis in patients with metastatic breast cancer. Leukemia patient with optic nerve head leukemic infiltrate before (E) and after (F) treatment. (G) Patient with CMV retinitis. (H) Optic nerve metastasis in a child with contralateral retinoblastoma. (I) A patient with optic disc swelling and normal optic nerve functions was found to have optic disc drusen confirmed by hyperreflectivity in B-scan (J).