contrecoup mechanism of injury to the optic nerve at its junction with the globe. The pathogenesis of this rare form of posttraumatic optic disc swelling is speculative. Possible inciting factors include chronic, low-grade ischemia secondary to traumatic posterior ciliary artery occlusion, axonal crowding secondary to edema of the peripapillary sclera, and posttraumatic posterior vitreous detachment in a young patient with strong vitreopapillary adhesions to the disc. The delayed visual recovery may relate to the ability of young patients to withstand chronic, low-grade optic disc ischemia.

CT scanning should be obtained to rule out an intrasheath hemorrhage in any child with decreased vision and optic disc edema following blunt ocular trauma, as vision can be restored by optic nerve sheath fenestration in this setting.218,256 Optic disc swelling secondary to intraocular inflammation or to hypotony (due to a cyclodialysis cleft or ciliary body hyposecretion) should also be considered in the context of posttraumatic optic disc swelling.

Intrinsic Optic Disc Tumors

Optic Disc Hemangioma

Capillary hemangiomas may occur within the substance of the disc as an isolated tumor (von Hippel’s disease) or in association with cerebellar and visceral tumors (von Hippel–Lindau disease). “Endophytic” hemangiomas appear as reddish, spherical, slightly elevated “knobs” that lie anterior to the disc vasculature (Fig. 3.15). The “endophytic” type of capillary hemangioma does not appear as a distinct mass but is typically seen as blurring and elevation of the disc margin, often associated with a serous detachment of the peripapillary retina.380 Hemangiomas of the optic disc may leak lipoprotein exudates into the retina and may be mistaken for either neuroretinitis or juxtapapillary choroidal neovascularization (Fig. 3.15).189,380 Fluorescein angiography shows early and diffuse filling confined to the area of the tumor, with late staining (Fig. 3.15). Histopathologically, the disc hemangioma consists of multiple thin-walled interconnecting aneurysms of variable size.189

Tuberous Sclerosis

Astrocytic hamartomas of the optic disc or peripapillary retina may produce optic disc elevation in tuberous sclerosis.412,575 These lesions typically protrude or overlie the optic disc and evolve from a gray or grayish-pink translucent appearance in infancy to a glistening, yellow, mulberry appearance later in childhood. Small calcified astrocytic hamartomas of the optic disc may be impossible to distinguish from disc drusen.189

Fig. 3.15  (a) Endophytic optic disc hemangioma in patient with von Hippel–Lindau disease. Area of fibrovascular proliferation overlies superior disc margin. (b) Early phase fluorescein angiogram showing discrete filling of lesion. Courtesy of Stephen C. Pollock, M.D. (c) Exophytic optic disc hemangioma with retinal exudate simulating neuroretinitis. Courtesy of Stephen P. Christiansen, M.D.