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Can an Ophthalmologist (Eye Doctor) Detect Intracranial Pressure?

I'm a former pharmacy technician and certified medical office assistant. I'm also a health nerd/ hypochondriac and knowledge eases my fears.

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Yes, your ophthalmologist can detect hints that may point towards intracranial pressure, but it's important to consider that not all cases of intracranial pressure cause noticeable changes to the eyes and vision.

On top of this, not all ophthalmologists will carry out the necessary tests that are needed to diagnose this serious condition.

To better understand how intracranial hypertension impacts your eyes and vision, it's helpful to first learn more about what happens in this condition and how it typically manifests.

What Is Intracranial Hypertension?

Intracranial hypertension, as the name implies, consists of a central nervous disorder characterized by increased pressure inside the skull. The word intracranial means "inside the skull" while the word "hypertension" means high pressure.

Many folks associate the word hypertension with high blood pressure, but in this case, hypertension refers to the high pressure of cerebrospinal fluid (the fluid that surrounds the brain) rather than blood.

There are two forms of intracranial hypertension: primary and secondary.

In the primary form, known as idiopathic intracranial hypertension (IIH), the condition occurs with an unknown cause. In other words, we don't know what causes it.

This form is commonly known for affecting females between the ages of 20 and 45 who are overweight, however, in reality, it can affect both males and females of all ages, regardless of weight.

Secondary intracranial hypertension instead is triggered by an underlying medical cause such as ingestion of certain types of drugs (tetracycline, lithium, excessive amounts of vitamin A, contraceptive pills, steroids), sleep apnea, lupus, leukemia, kidney failure, meningitis, thyroid dysfunction, Chiari malformation, dural venous sinus thrombosis.

What Problems Does Intracranial Hypertension Cause?

When there is high pressure of cerebrospinal fluid within the skull, this mainly leads to two problems.

Headaches are one of them and are estimated to occur in 92 percent of sufferers. The headaches are typically persistent and severe, although some people may suffer from less painful forms.

Typically, the pain is described as being localized frontally or behind the eyes. However, there is great variability with some people reporting it having a bilateral natural or sharing several features with migraines such as unilateral throbbing.

These headaches can lead to light sensitivity, nausea, and vomiting and typically don't respond to medications.

The throbbing headaches may awaken the sufferer at night and tend to worsen upon getting up in the morning (due to increased intracranial pressure when lying flat). Such headaches may also be aggravated by things like sneezing, coughing, bending down, or standing.

Serious eye problems are another problem and these can lead to vision loss and even blindness.

On top of these problems, other symptoms include pulsatile tinnitus (a whooshing sound, synchronous with heartbeat), neck stiffness, pain in the back, arm, and behind the eye, dizziness, exercise intolerance, and difficulty remembering things.

A field vision test can help check for loss of peripheral vision.

A field vision test can help check for loss of peripheral vision.

What Kind of Eye Problems Are Caused By Intracranial Hypertension?

When there is high pressure of cerebrospinal fluid in the skull, this can cause a part of the optic nerve inside the eye (the optic disc) to swell, a condition that is medically known as papilledema.

The optic disc is the point where the optic nerve enters the back of the eyeball. This nerve is responsible for relaying messages from the retina to the brain so to create visual images.

When the optic disc swells due to compression, it risks causing injury to the optic nerve fibers. Because this nerve carries visual information from the eye to the brain allowing you to see, when its functionality becomes impaired, this leads to vision problems.

Sufferers may experience subtle changes such as blurred vision, double vision, flickers of gray vision, flashing lights, a decreased field of vision, or they may struggle to see colors. Eyesight may appear altered when standing up such as after bending down or moving.

Several sufferers develop a sudden, transient darkening of vision (transient visual obscuration) impacting one or both eyes. This tends to last less than 30 seconds and can happen, in particular, early in the morning or after postural changes.

It can happen in one or both eyes, although, usually, both eyes are affected. Left untreated, this condition can lead to blindness.

How Can Ophthalmologists Detect Intracranial Pressure?

There are several tests that can help ophthalmologists (or even better neuro-ophthalmologists) detect problems with vision and the optic nerve. Following are some.

Ophthalmoscopy (Fundoscopy)

This test allows experts to look inside the back of the eyes using a light with magnifying lenses. This test can identify the presence and grade of papilledema.

In a normal situation, the optic disc appears pink with a clear border and blood vessels are smooth and normal.

In a situation where intracranial pressure increases, the cerebrospinal fluid causes compression, leading to the edges of the disc appearing blurry and swollen, while becoming elevated with the veins appearing engorged (venous engorgement).

The papilledema is graded from 0 to 5 based on severity, with 0 being a normal-looking disc and 5 depicting severe swelling.

It's important to note though, once again, that there are individual variances. Some sufferers with high intracranial pressure will have no papilledema or visual symptoms, while others with just mild papilledema will have significant visual deficits.

The Visual Field Test

This test involves the presentation of fixed points of light shown at different intensity levels. The patient will need to press on a button every time a light is seen.

In this test, one of the earliest signs of papilledema (swelling of optic disc) is blind spot enlargement.

In the initial stages, blind spot enlargement and nasal defects are detected. As the condition progresses, the blind spots may continue to involve the center of the visual field.

Severe devastating and permanent visual field loss may result when intracranial pressure is not promptly treated.

Optical Coherence Tomography (OCT)

This test allows us to visualize the optic nerve and any associated swelling. It uses reflected light to attain a detailed image of the back of the eye and optic nerve.

Can You Have Intracranial Hypertension Without Papilledema?

Yes. A study has found that only 5.7 percent of patients diagnosed with idiopathic intracranial hypertension did not have papilledema.

What Happens if Papilledema Is Noticed?

The ophthalmologist will likely tell the patient to visit an emergency department considering the potentially serious underlying disease.

This should prompt deeper investigation, such as having a CT scan or MRI to check for brain pressure, or a lumbar puncture (spinal tap) for the purpose of checking for fluid pressure in the spine.

If detected early enough, papilledema can be successfully treated with medications and other therapies. However, it is important to maintain regular follow-up visits.

Visual field defects are often reversible if the intracranial pressure is reduced before damage occurs to the optic nerve.

What Are My Chances of Having Intracranial Hypertension?

One good news is that intracranial hypertension is fairly rare. Indeed, it affects about 1 in 100,000 people. In overweight young females, its incidence increases, and is about 20 per 100,000, making this a condition that will expand considering the increase in obesity worldwide.

Prevalence and Signs of Idiopathic Intracranial Hypertension

SignsIncidenceNotes

Female

Over 90 percent (age 15 to 44)

Less than 10% of IIH patients are male

Obese

20% or more over ideal weight

Body mass index (BMI) greater than 30

Headaches

Seen in 92 percent of sufferers

Skin sensitive to touch

Seen in 50 percent of sufferers

Transient Vision Loss

Seen in 72 percent of sufferers

Males may have worse visual outcomes than females

Vision field defects in at least one eye

Seen in 92 percent sufferers

Assessed with the Humphrey perimeter

Double vision

Seen in one-third to two-thirds of sufferers

Pulsatile tinnitus

Seen in 52 percent of sufferers

References

  • National Organization for Rare Disorders, Inc. Idiopathic Intracranial Hypertension
  • Mollan SP, Markey KA, Benzimra JD, et alA practical approach to, diagnosis, assessment and management of idiopathic intracranial hypertensionPractical Neurology 2014;14:380-390
  • Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (beta version) Cephalalgia 2013;33:629-808
  • Akçakaya et al.; Idiopathic Intracranial Hypertension Turk J Neurol 2017;23:43-50
  • Digre KB, Nakamoto BK, Warner JE, Langeberg WJ, Baggaley SK, Katz BJ. A comparison of idiopathic intracranial hypertension with and without papilledema. Headache. 2009 Feb;49
  • Neuro-ophthalmology Illustrated-2nd Edition. Biousse V and Newman NJ. 2012. Theme
  • Practical Neurology, Idiopathic Intracranial Hypertension: Papilledema and Neuro-Ophthalmology Referral Patterns
  • Chen J, Wall M. Epidemiology and risk factors for idiopathic intracranial hypertension. Int Ophthalmol Clin. 2014 Winter;54
  • Wall M, George D. Idiopathic intracranial hypertension. A prospec-tive study of 50 patients. Brain 1991
  • Visual loss in pseudotumor cerebri. Follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss. Corbett JJ, Savino PJ, Thompson HS, et al Arch Neurol 1982
  • Idiopathic Intracranial Hypertension Explained A Guide for Patients and Families 1st ed. 2021 Kyle M. Fargen
  • Keltner JL, Johnson CA, Cello KE, Wall M; NORDIC Idiopathic Intracranial Hypertension Study Group. Baseline visual field findings in the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT). Invest Ophthalmol Vis Sci. 2014 Apr 29

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2022 Adrian Rolla