Accuracy of Diagnostic Imaging Modalities for Classifying Pediatric Eyes as Papilledema Versus Pseudopapilledema

The membrane-associated ubiquitin ligase MARCHF8 promotes cancer immune evasion by degrading MHC class I proteins

The loss of major histocompatibility complex class I (MHC-I) molecules has been proposed as a mechanism by which cancer cells evade tumor-specific T cells in immune checkpoint inhibitor (ICI)-refractory patients. Nevertheless, the mechanism by which cancer cells downregulate MHC-I is poorly understood. We report here that membrane-associated RING-CH-type finger 8 (MARCHF8), upregulated by human papillomavirus (HPV), ubiquitinates and degrades MHC-I proteins in HPV-positive head and neck cancer (HPV+ HNC). MARCHF8 knockdown restores MHC-I levels on HPV+ HNC cells. We further reveal that Marchf8 knockout significantly suppresses tumor growth and increases the infiltration of natural killer (NK) and T cells in the tumor microenvironment (TME). Furthermore, Marchf8 knockout markedly increases crosstalk between the cytotoxic NK cells and CD8 + T cells with macrophages and enhances the tumor cell-killing activity of CD8 + T cells. CD8 + T cell depletion in mice abrogates Marchf8 knockout-driven tumor suppression and T cell infiltration. Interestingly, Marchf8 knockout, in combination with anti-PD-1 treatment, synergistically suppresses tumor growth in mice bearing ICI-refractory tumors. Taken together, our finding suggests that MARCHF8 could be a promising target for novel immunotherapy for HPV+ HNC patients.

One Sentence Summary

Targeting MARCHF8 restores MHC-I proteins, induces antitumor CD8 + T cell activity, and suppresses the growth of ICI-refractory tumors.

Application of Optical Coherence Tomography Angiography in True and Pseudo-Optic Disc Swelling

Purpose

We evaluated the optic disc microvasculature in healthy subjects and patients with optic nerve head drusen (ONHD), active papilledema, and acute nonarteritic anterior ischemic optic neuropathy (NAION) using optical coherence tomography angiography (OCTA).

Methods

This prospective, comparative case series included sixteen eyes with ONHD, thirty-one eyes with active papilledema, sixteen eyes with acute NAION, and thirty-two healthy eyes. The Optovue AngioVue OCT and OCTA Imaging System recorded peripapillary retinal nerve fiber layer (RNFL) thickness and vessel density maps from the radial peripapillary capillary (RPC) slab.

Results

Average RNFL thicknesses were greater in eyes with ONHD, papilledema, and NAION compared to control eyes (all Ps < 0.001), but this parameter did not differ among patient groups. The mean peripapillary vessel density did not differ between the ONHD and control groups (P=1.000), nor between the NAION and papilledema groups (P=0.216). However, this value in the ONHD and control groups was significantly higher than in the NAION and papilledema groups (all Ps < 0.05).

Conclusion

RPC density is influenced during the progression of conditions such as ONHD, papilledema, and NAION. Although a decrease in vessel density values has been observed in cases of true disc edema, further research is necessary to assess the potential of OCTA in differentiating between true and pseudo-optic disc edema.

Diagnostic utility of point-of-care ultrasound and optical coherence tomography for papilloedema in children: a prospective pilot study

BACKGROUND/AIMS

Papilloedema is an important sign of serious neurological disease, but it can be difficult to detect on funduscopy. The purpose of this study was to determine the diagnostic accuracy of point-of-care ultrasound (POCUS) and optical coherence tomography (OCT) for detecting papilloedema in children.

METHODS

This was a prospective observational study at a tertiary care paediatric hospital. Patients were eligible for the study if they underwent a lumbar puncture with opening pressure and had high-quality POCUS and OCT imaging.

RESULTS

A total of 63 eyes from 32 patients were included in the study, 41 (65%) with papilloedema and 22 (35%) without. There were statistically significant differences between the groups in the optic disc elevation (ODE) (p<0.001) and optic nerve sheath diameter (ONSD) (p<0.001) on POCUS, and in the average retinal nerve fibre layer (rNFL) thickness on OCT (p<0.001). Average rNFL thickness had the highest diagnostic accuracy with an area under the curve (AUC) of 0.999 and a 100% sensitivity and 95% specificity for papilloedema (threshold value of ≥108 µm). ODE had an AUC of 0.866 and a 93% sensitivity and 55% specificity (threshold value of ≥0.5 mm). ONSD had an AUC of 0.786 and a 93% sensitivity and 45% specificity (threshold value of ≥5.5 mm).

CONCLUSION

Both OCT and POCUS are potentially useful tools to help diagnose papilloedema in children. Larger studies are needed to further define the role and accuracy of POCUS and OCT in assessing papilloedema in children.

Artificial Intelligence to Differentiate Pediatric Pseudopapilledema and True Papilledema on Fundus Photographs

Purpose

To develop and test an artificial intelligence (AI) model to aid in differentiating pediatric pseudopapilledema from true papilledema on fundus photographs.

Design

Multicenter retrospective study.

Subjects

A total of 851 fundus photographs from 235 children (age < 18 years) with pseudopapilledema and true papilledema.

Methods

Four pediatric neuro-ophthalmologists at 4 different institutions contributed fundus photographs of children with confirmed diagnoses of papilledema or pseudopapilledema. An AI model to classify fundus photographs as papilledema or pseudopapilledema was developed using a DenseNet backbone and a tribranch convolutional neural network. We performed 10-fold cross-validation and separately analyzed an external test set. The AI model's performance was compared with 2 masked human expert pediatric neuro-ophthalmologists, who performed the same classification task.

Main Outcome Measures

Accuracy, sensitivity, and specificity of the AI model compared with human experts.

Results

The area under receiver operating curve of the AI model was 0.77 for the cross-validation set and 0.81 for the external test set. The accuracy of the AI model was 70.0% for the cross-validation set and 73.9% for the external test set. The sensitivity of the AI model was 73.4% for the cross-validation set and 90.4% for the external test set. The AI model's accuracy was significantly higher than human experts on the cross validation set (P < 0.002), and the model's sensitivity was significantly higher on the external test set (P = 0.0002). The specificity of the AI model and human experts was similar (56.4%-67.3%). Moreover, the AI model was significantly more sensitive at detecting mild papilledema than human experts, whereas AI and humans performed similarly on photographs of moderate-to-severe papilledema. On review of the external test set, only 1 child (with nearly resolved pseudotumor cerebri) had both eyes with papilledema incorrectly classified as pseudopapilledema.

Conclusions

When classifying fundus photographs of pediatric papilledema and pseudopapilledema, our AI model achieved > 90% sensitivity at detecting papilledema, superior to human experts. Due to the high sensitivity and low false negative rate, AI may be useful to triage children with suspected papilledema requiring work-up to evaluate for serious underlying neurologic conditions.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Diagnostic dilemma of papilledema and pseudopapilledema

BACKGROUND

Papilledema is the optic disc swelling caused by increased intracranial pressure (ICP) that can damage the optic nerve and cause subsequent vision loss. Pseudopapilledema refers to optic disc elevation without peripapillary fluid that can arise from several optic disc disorders, with optic disc drusen (ODD) being the most frequent cause. Occasionally, pseudopapilledema patients are mistakenly diagnosed as papilledema, leading to the possibility of unneeded procedures. We aim to thoroughly examine the most current evidence on papilledema and pseudopapilledema causes and several methods for distinguishing between both conditions.

METHODS

An extensive literature search was conducted on electronic databases including PubMed and google scholar using keywords that were relevant to the assessed pathologies. Data were collected and then summarized in comprehensive form.

RESULTS

Various techniques are employed to distinguish between papilledema and pseudopapilledema. These techniques include Fundus fluorescein angiography, optical coherence tomography, ultrasonography, and magnetic resonance imaging. Lumbar puncture and other invasive procedures may be needed if results are suspicious.

CONCLUSION

Papilledema is a sight-threatening condition that may lead to visual affection. Many disc conditions may mimic papilledema. Accordingly, differentiation between papilledema and pseudopailledema is crucial and can be conducted through many modalities.

Oral fluorescein angiography in the diagnosis of paediatric optic nerve abnormalities

OBJECTIVE

FFA is a well-established investigation for the diagnosis of optic nerve abnormalities, requiring an intravenous cannula and extended imaging acquisition time. Cannulation can present a challenge in paediatric patients and whilst oral FFA has been used for decades, it has been limited by imaging technology and unconfirmed image acquisition timings. For years, we have used a modern ultra-widefield retinal camera, and established imaging time-points to demonstrate dynamic optic nerve head changes upon ingestion of fluorescein and collected a database of oFFA images for various presentations.

METHODS

Using an established protocol, optic nerve colour images were obtained, followed by oral administration of fluorescein dye. The optic nerves are then imaged at established intervals. An interpretation of oFFA tutorial was delivered to consultant ophthalmologists and trainees. Subsequently, these groups were assessed using a series of fifteen cases with the sensitivity and specificity of the test determined.

RESULTS

Our study presents a series of images and descriptions for common optic nerve abnormalities in paediatric populations. In the interpretation part of the study, overall sensitivity of 76.8% in the consultant group vs 63.3% in the combined consultant + trainees and specificity of 87.5% vs 68.4% in the combined group.

CONCLUSIONS

This is the first study that describes characteristic features of several common, and serious, optic nerve abnormalities specifically for oFFA interpretation in a paediatric population. It also highlights the rapid accumulation of oFFA interpretation skills in non-specialist consultant and trainee ophthalmologists such as to obtain a high diagnostic accuracy with high sensitivity and specificity.

[Importance of fluorescein angiography for differentiating between early papilledema and papillitis]

BACKGROUND

Optic disc swelling poses a diagnostic challenge due to its multiple underlying pathological causes. This study aimed to investigate the use of fluorescein angiography (FLA) in combination with optical coherence tomography (OCT) as a diagnostic tool for differentiating between papilledema and papillitis in cases of optic disc swelling.

MATERIAL AND METHODS

A total of 12 patients were included in the study in whom both FLA and OCT of the optic disc were performed to evaluate the optic disc swelling in cases of papilledema (7 patients, 14 eyes) and papillitis (5 patients, 7 eyes). The fluorescence behavior of the optic disc during late phase FLA was examined in relation to papillary thickness measured by OCT.

RESULTS AND DISCUSSION

In the papilledema group OCT revealed a mean papillary thickness of 873 µm. In 6 patients FLA detected a ring-shaped papillary hyperfluorescence with papillary thicknesses ranging from 611 µm to 972 µm. Another patient with chronic and marked papilledema exhibited bilateral panpapillary leakage in FLA and papillary thicknesses of 1287 µm (right eye) and 1526 µm (left eye). In the papillitis group FLA showed panpapillary leakage in all cases. The mean papillary thickness was 865 µm (range 632-1195 µm).

CONCLUSION

In acute optic disc swelling and a papillary prominence less than 1000 µm in OCT, a difference in FLA was noticeable between papilledema and papillitis. While acute and mild papilledema exhibited a ring-shaped hyperfluorescence, papillitis showed a panpapillary leakage in late phase FLA in the examined cases. This difference could not be seen in the case of papilledema with chronic and severe swelling.

Clinical approach for suspected optic disc swelling in children: recommendations based on a six-year review

CLINICAL RELEVANCE

Suspected optic disc swelling is a common presentation in children. The delineation between true optic disc swelling and pseudopapilloedema, its common masquerade, requires careful evaluation. A streamlined pathway is required to avoid unnecessary investigations.

BACKGROUND

Papilloedema requires urgent neuroimaging, however, perceived optic disc swelling is not always true papilloedema. This study aims to investigate the outcome of referrals for optic disc swelling and formulate features that may assist in investigation and diagnosis.

METHODS

A retrospective review of referrals for optic disc swelling to the Queensland Children's Hospital, Australia, between January 2014 and June 2020 was undertaken.

RESULTS

Four hundred and ten children were referred for optic disc swelling. Sixty-six patients were confirmed with optic disc swelling, and 344 patients had pseudopapilloedema. The average age was 10.10 ± 3.57 and 9.90 ± 3.50 years, respectively. The most common aetiology of optic disc swelling was idiopathic intracranial hypertension (n = 25). Optic disc drusen constituted the majority of pseudopapilloedema (n = 239) and the remainder were crowded/tilted discs (n = 105). True optic disc swelling patients were more likely to experience headache (OR = 8.68, p < 0.01) and visual disturbance (OR = 2.14, p = 0.03). B-scan was the most sensitive for the detection of optic disc drusen (100%), followed by optical coherence tomography (70.38%) and fundus autofluorescence (44.86%). The retinal nerve fibre layer thickness was significantly thicker in true optic disc swelling compared to pseudopapilloedema (p < 0.01). Twenty-two (33.33%) true optic disc swelling patients and 33 (9.59%) pseudopapilloedema patients underwent neuroimaging prior to ophthalmology review.

CONCLUSIONS

Suspected optic disc swelling in children is most likely pseudopapilloedema. Referrals should include neurological assessment, visual acuity, fundus photography, and optical coherence tomography to assist in the triage for ophthalmic review. Neuroimaging prior to ophthalmic review should be discouraged for children without neurological symptoms.

Influence of Patient Age and Presence of Optic Disc Drusen on Fluctuations in Retinal Nerve Fiber Layer Thickness

BACKGROUND

It is generally believed that optic disc drusen (ODD) change only over long periods of time. Because, in our experience, this does not apply to younger patients, we investigated the natural course of changes of the peripapillary retinal nerve fiber layer (RNFL) in patients with ODD.

METHODS

In this retrospective study, 40 eyes with and 40 eyes without ODD were examined, both cohorts were equally subdivided into younger subjects (20 years or younger) and older subjects (21 years or older). Three optical coherence tomography (OCT) scans of the peripapillary RNFL that had an interval of at least 1 month were required for each patient to be included in this study. The largest difference in total RNFL thickness (delta RNFL-t) and in RNFL thickness of the most differing sector (delta RNFL max) measured by OCT was compared.

RESULTS

The differences in total RNFL thickness and in the most differing RNFL sector in the group of patients with ODD younger than 21 years were significantly larger than in each of the other 3 groups ( P = 0.0001). The other 3 groups did not differ significantly.

CONCLUSIONS

Patients with ODD younger than 21 years have distinct variations in peripapillary RNFL thickness without evidence of increased intracranial pressure. In the absence of further pathological findings or neurological symptoms, an observational approach seems adequate in these patients.

Ultrasound detected increase in optic disk height to identify elevated intracranial pressure: a systematic review

BACKGROUND

Elevated intracranial pressure (eICP) is a serious medical emergency that requires prompt identification and monitoring. The current gold standards of eICP detection require patient transportation, radiation, and can be invasive. Ocular ultrasound has emerged as a rapid, non-invasive, bedside tool to measure correlates of eICP. This systematic review seeks to explore the utility of ultrasound detected optic disc elevation (ODE) as an ultrasonographic finding of eICP and to study its sensitivity and specificity as a marker of eICP.

METHODS

This systematic review followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We systematically searched PubMed, EMBASE, and Cochrane Central for English articles published before April 2023; yielding 1,919 total citations. After eliminating duplicates, and screening the records, we identified 29 articles that addressed ultrasonographically detected ODE.

RESULTS

The 29 articles included a total of 1249 adult and pediatric participants. In patients with papilledema, the mean ODE ranged between 0.6 mm and 1.2 mm. Proposed cutoff values for ODE ranged between 0.3 mm and 1 mm. The majority of studies reported a sensitivity between 70 and 90%, and specificity ranged from 69 to 100%, with a majority of studies reporting a specificity of 100%.

CONCLUSIONS

ODE and ultrasonographic characteristics of the optic disc may aid in differentiating papilledema from other conditions. Further research on ODE elevation and its correlation with other ultrasonographic signs is warranted as a means to increase the diagnostic accuracy of ultrasound in the setting of eICP.

Peripapillary hyper-reflective ovoid mass-like structures (PHOMS): clinical significance, associations, and prognostic implications in ophthalmic conditions

Pioneering advancements in optical coherence tomography (OCT) have facilitated the discernment of peripapillary hyper-reflective ovoid mass-like structures (PHOMS), prevalent neuro-ophthalmological findings associated with an array of ophthalmic conditions, such as optic disc drusen (ODD), papilledema, myopic/tilted optic discs, non-arteritic anterior ischemic optic neuropathy (NA-AION), and optic neuritis. Despite an expanding corpus of research, numerous inquiries persist concerning their clinical significance, correlations with ocular afflictions, and prognostic implications. This comprehensive review endeavors to impart an in-depth comprehension of PHOMS, encompassing facets like conceptualization, detection, pathogenesis, and associations with diverse ophthalmic conditions. Furthermore, we underscore several unresolved quandaries and suggest prospective avenues for future exploration.

Oral Fluorescein Angiography for the Diagnosis of Papilledema Versus Pseudopapilledema in Children

PURPOSE

To evaluate the accuracy and safety of oral fluorescein angiography (OFA) in differentiating papilledema from pseudopapilledema in pediatric patients.

DESIGN

Retrospective evaluation of a diagnostic test.

METHODS

We retrospectively reviewed medical records of all children ≤18 years of age who presented to the Arkansas Children's Hospital between May 2018 and August 2021 with suspected optic disc (OD) swelling that had OFA and images >30 minutes after oral ingestion. Two masked specialists interpreted the images as either OD leakage, no leakage, or borderline leakage. Optic disc swelling was graded clinically according to the Frisen grading scale (0-5). We compared OFA images to the final clinical diagnosis and calculated the accuracy of the test as follows: (number of eyes correctly identified as papilledema [true positive] + number of eyes correctly identified as pseudopapilledema [true negative]) / (total number of eyes) × 100%.

RESULTS

Forty-five patients (90 eyes) were included, 11 patients with papilledema and 34 with pseudopapilledema. The mean age was 14.1 ± 3.5 years; 66.7% were female. The accuracy of OFA was 62% for reviewer 1 and 69% for reviewer 2. No ocular or systemic side effects after OFA were observed. There was substantial agreement (k = 0.779) between both reviewers in grading the OFA images.

CONCLUSION

OFA cannot definitively distinguish papilledema from pseudopapilledema in children and should be interpreted in conjunction with other clinical findings.

An overview of peripapillary hyperreflective ovoid mass-like structures

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the ophthalmic findings associated with peripapillary hyperreflective ovoid mass-like structures (PHOMS) in both adult and pediatric patients.

RECENT FINDINGS

PHOMS have recently been identified in a number of different ophthalmic disease entities ranging from nonpathologic to pathologic, including but not limited to anatomic abnormalities (tilting in myopia), optic nerve head drusen, optic disc edema from inflammation (optic neuritis, white dot syndromes), vascular insults (ischemic optic neuropathy, retinal vascular occlusion), and papilledema. The mechanism underlying the formation of PHOMS has not been fully elucidated although it has been hypothesized that PHOMS occur secondary to axoplasmic stasis from crowding at the optic nerve head.

SUMMARY

Although the clinical significance of the presence of PHOMS remains unclear, PHOMS are associated with several disease processes. Understanding the mechanism behind their formation and their impact on optic nerve head structure and visual function may be relevant in patients with optic nerve head pathology. The presence of PHOMS may also correlate with disease severity and duration. Future studies to evaluate whether the formation of PHOMS may be useful as an early indicator of disease or a prognostic tool are warranted.

Peripapillary hyperreflective ovoid masslike structures in a pediatric population referred for suspected papilledema

BACKGROUND

Peripapillary hyperreflective ovoid masslike structures (PHOMS) are now considered a common cause of pseudopapilledema in the pediatric population.

METHODS

The medical records of all patients ≤18 years of age with PHOMS, confirmed on optical coherence tomography, seen at single pediatric neuro-ophthalmology clinic between 2017 and 2021 were reviewed retrospectively.

RESULTS

A total of 47 patients (35 females), with median age of 12.7 years at initial visit, were included. Of these, 24 (51%) of patients were optometry referrals. Headache was a common symptom. PHOMS were present bilaterally in all patients and were 360° around the disk in 57 of 94 eyes (61%). Patients with elevated intracranial pressure were more likely to have a reduction in the size of PHOMS at follow-up (P = 0.0133). Of the 47, 40 (85%) had diagnostic neuroimaging as a part of their papilledema workup. The retinal nerve fiber layer was thicker in patients with concomitant papilledema rather than optic disk drusen (P = 0.002) and compared with patients with PHOMS alone (P = 0.00051).

CONCLUSIONS

Pediatric patients with PHOMS may be referred because their clinical appearance can be suggestive of papilledema. In our study cohort, PHOMS were bilateral and frequently occurred concurrently with other ophthalmic conditions.

Upper Limit of Retinal Nerve Fibre Layer Thickness in Patients with Pseudopapilloedema

An initial misdiagnosis of papilloedema in a patient with optic nerve head swelling can be anxiety-provoking and may result in unnecessary, invasive, and costly tests. Cirrus high definition, spectral domain-optical coherence tomography (Cirrus HD-OCT) may provide a rapid and non-invasive test. We sought to determine an upper limit of average retinal nerve fibre layer (RNFL) thickness in patients with pseudopapilloedema without visible drusen using Cirrus HD-OCT that could be utilised in conjunction with the clinical presentation and physical examination when managing patients with optic nerve head swelling. Inclusion criteria consisted of at least two neuro-ophthalmological visits and repeated imaging of the optic nerve head with Cirrus HD-OCT at least 6 months apart. Exclusion criteria included clinically visible drusen along with previous or concomitant diagnosis of retinal or other optic nerve pathology. Thirty-eight eyes from 19 patients with pseudopapilloedema were included in this study. The upper limit of average RNFL thickness was defined as two standard deviations above the mean of the average RNFL thickness and was calculated to be 158.65 µm for scans obtained with Cirrus HD-OCT devices. A patient with suspected optic nerve head swelling, an average RNFL thickness less than 158.65 µm, and no other evidence of papilloedema or neurological signs or symptoms can be managed with serial follow-ups with OCT imaging for at least 6 months. If the patient continues to have no clinical symptoms suggesting increased intracranial pressure and the average RNFL thickness is stable, the likelihood of papilloedema is minimal.

Optic Disc Edema and Elevated Intracranial Pressure (ICP): A Comprehensive Review of Papilledema

Papilledema is a swelling of the optic disc secondary to elevated intracranial pressure (ICP). We analyzed 79 peer-review journal articles and provided a concise summary of the etiology, epidemiology, pathophysiology, clinical presentation, evaluation, natural history, differential diagnosis, treatment, and prognosis of papilledema. Only studies written in English with the full text available were included. Although many etiologies of papilledema exist, idiopathic intracranial hypertension is the most common and, thus, a large focus of this review.

Idiopathic intracranial hypertension: Pathophysiology, diagnosis and management

Idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure, manifested by papilledema and radiological findings, in the absence of an identifiable casual factor. The primary symptoms include headache, vision loss, and pulsatile tinnitus, and are recognized to have profound impacts on quality of life and visual function. IIH demonstrates a strong predilection towards obese women of reproductive age, and the population incidence is rising with the growing prevalence of obesity worldwide. The pathophysiology involves dysregulation of cerebrospinal fluid (CSF) dynamics and venous sinus pressure, and recent studies highlighting the pathogenic role of metabolic and hormonal factors have led to the identification of several pharmacological targets and development of novel therapeutic agents. The overarching treatment goals include symptomatic alleviation and prevention of permanent vision loss. The Idiopathic Intracranial Hypertension Treatment Trial, the first of its kind randomized controlled trial on IIH, provides class I evidence for treatment with weight loss and acetazolamide. In medically refractive or fulminant cases, optic nerve sheath fenestration, CSF diversion, and venous sinus stenting, have been successfully implemented. However, there are few high-quality prospective studies investigating the treatment and natural history of IIH, highlighting the compelling need for further research to determine the optimal treatment regimen.

Variability Within Optic Nerve Optical Coherence Tomography Measurements Distinguishes Papilledema From Pseudopapilledema

BACKGROUND

To report a linear risk score obtained using clock-hour optical coherence tomography (OCT) data from papilledema and pseudopapilledema nerves that differentiates between the 2 diagnoses with high sensitivity and specificity.

METHODS

Patients presenting to a single neuro-ophthalmologist with papilledema or pseudopapilledema were included for a retrospective review. The absolute consecutive difference in OCT retinal nerve fiber layer (RNFL) thickness between adjacent clock hours and the mean magnitude of thickness for clock hours 1-12 were compared between the 2 groups using mixed-effect models adjusting for age and clock hour with a random intercept for subjects and eyes (nested within subject). The area under the curve (AUC) for the receiver operating characteristics curve and a separate calibration curve was used to evaluate potential clinical usage.

RESULTS

Forty-four eyes with papilledema and 72 eyes with pseudopapilledema, 36 of whom had optic nerve drusen met criteria. The papilledema group had a higher mean RNFL thickness (papilledema = 163 ± 68 µm, pseudopapilledema = 82 ± 22 µm, P < 0.001). The papilledema groups also had more variability between consecutive clock hours (papilledema = 57 ± 20 µm, pseudopapilledema = 26 ± 11 µm, P < 0.001). A linear combination of each patient's averaged values separated the 2 groups with an AUC of 98.4% (95% CI 95.5%-100%) with an optimized sensitivity of 88.9% and specificity of 95.5% as well as good calibration (mean absolute error = 0.015).

CONCLUSIONS

Patients with papilledema have higher intrinsic variability and magnitude within their OCT, and this finding reliably distinguishes them from those with pseudopapilledema.

Peripapillary Hyper-reflective Ovoid Mass-like Structure (PHOMS): An Optical Coherence Tomography Marker of Axoplasmic Stasis in the Optic Nerve Head

BACKGROUND

With the development and widespread adoption of spectral-domain optical coherence tomography (OCT), peripapillary hyper-reflective ovoid mass-like structures (PHOMS) have become a frequent OCT finding in neuro-ophthalmic practice. Although originally assumed to represent a form of buried optic disc drusen (ODD), PHOMS differ from ODD in many important ways. The histopathological underpinnings of PHOMS are now becoming more clearly understood.

EVIDENCE ACQUISITION

Review of literature.

RESULTS

PHOMS can be broadly classified as disk edema-associated PHOMS, ODD-associated PHOMS, or anomalous disk-associated PHOMS. PHOMS are seen in many conditions, including papilledema, nonarteritic anterior ischemic optic neuropathy, central retinal vein occlusion, acute demyelinating optic neuritis, ODD, and tilted disks (myopic obliquely inserted disks) and in many cases resolve along with the underlying condition. The histopathological study of these diverse entities reveals the common feature of a bulge of optic nerve fibers herniating centrifugally over Bruch membrane opening into the peripapillary space, correlating exactly with the location, shape, and space-occupying nature of PHOMS on OCT. Because of the radial symmetry of these herniating optic nerve fibers, PHOMS are best thought of as a complete or partial torus (i.e., donut) in 3 dimensions.

CONCLUSIONS

PHOMS are a common but nonspecific OCT marker of axoplasmic stasis in the optic nerve head. They are not themselves ODD or ODD precursors, although they can be seen in association with ODD and a wide spectrum of other conditions. They do not exclude papilledema and often accompany it. The circumferential extent and characteristic 3D toroidal nature of a PHOMS are best appreciated by scrolling through consecutive OCT images.

Utility of Ultrasound and Optical Coherence Tomography in Differentiating Between Papilledema and Pseudopapilledema in Children

BACKGROUND

Differentiating between papilledema and pseudopapilledema in children presenting with mild-to-moderate optic nerve head elevation is challenging. This study sought to determine which B-scan ultrasonography (BSUS) and optical coherence tomography (OCT) features, individually or in combination, are best able to differentiate between papilledema and pseudopapilledema in children.

METHODS

Children presenting with optic nerve head elevation of unknown etiology were eligible if they underwent BSUS and OCT performed by the same investigator. The absolute optic nerve sheath diameter (in millimeter) along with the presence/absence of a hyperreflective nodule(s) at the optic nerve head (indicative of druse) from BSUS was determined. The average circumpapillary retinal nerve fiber layer (cpRNFL), diameter of Bruch membrane opening, maximum papillary height, and the presence/absence of hyper-/hyporeflective lesions at the optic nerve head were calculated. Sensitivity and specificity were calculated to evaluate which BSUS and OCT imaging features, individually and in combination, accurately classified children as having papilledema vs pseudopapilledema.

RESULTS

One hundred eighty-one eyes from 94 children (mean age, 11.0 years; range, 3.2-17.9) were included; 36 eyes with papilledema and 145 eyes with pseudopapilledema. Among BSUS features, optic nerve sheath widening (>4.5 mm) demonstrated the best sensitivity (86%; 95% confidence interval [CI], 64%-96%) and specificity (88%; 95% CI, 79%-94%) for papilledema. Among OCT measures, cpRNFL thickness of ≥140 µm demonstrated the best sensitivity (83%; 95% CI, 66%-93%) and specificity (76%; 95% CI, 66%-84%) to identify papilledema. The presence of both optic nerve sheath widening (>4.5 mm) and cpRNFL thickness of ≥140 µm reduced the sensitivity (72%; 95% CI, 52%-86%) but increased specificity (95%; 95% CI, 88%-98%).

CONCLUSION

BSUS (optic nerve sheath widening [>4.5 mm]) and OCT (cpRNFL thickness ≥140 µm), individually and collectively, have good diagnostic accuracy for differentiating between papilledema and pseudopapilledema. The presence of druse does not exclude the diagnosis of papilledema.

Detection of intracranial hypertension in children using optical coherence tomography: a systematic review

OBJECTIVES

To evaluate the diagnostic capability of optical coherence tomography (OCT) in children aged under 18 years old with intracranial hypertension (IH).

DESIGN

Systematic review.

METHODS

We conducted a systematic review using the following platforms to search the keywords 'optical coherence tomography' and 'intracranial hypertension' from inception to 2 April 2020: Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PubMed and Web of Science, without language restrictions. Our search returned 2729 records, screened by two independent screeners. Studies were graded according to the Oxford Centre for Evidence-Based Medicine and National Institutes of Health Quality Assessment Tool for observational studies.

RESULTS

Twenty-one studies were included. Conditions included craniosynostosis (n=354 patients), idiopathic IH (IIH; n=102), space-occupying lesion (SOL; n=42) and other pathology (n=29). OCT measures included optic nerve parameters, rim parameters (notably retinal nerve fibre layer thickness) and retinal parameters. Levels of evidence included 2b (n=13 studies), 3b (n=4) and 4 (n=4). Quality of 10 studies was fair and 11 poor. There was inconsistency in OCT parameters and reference measures studied, although OCT did demonstrate good diagnostic capability for IH in craniosynostosis, IIH and SOL.

CONCLUSIONS

This systematic review identified various studies involving OCT to assist diagnosis and management of IH in children with craniosynostosis, IIH, SOL and other pathology, in conjunction with established clinical measures of intracranial pressure. However, no level 1 evidence was identified. Validating prospective studies are, therefore, required to determine optimal OCT parameters in this role and to develop formal clinical guidelines.

PROSPERO REGISTRATION NUMBER

CRD42019154254.

Fundus autofluorescence in premature infants

To describe fundus autofluorescence (FAF) patterns in premature infants and to determine whether FAF increases gradually with increasing post-gestational age. This was a cross-sectional, observational and descriptive case series. FAF images were obtained from patients screened for Retinopathy of Prematurity. The presence of the following hypo-autofluorescence areas/structures was graded and ranked: macular pigment (foveal centre), optic nerve head, peripapillary vessels/vascular arcade (PP/VA), and equatorial vessels (EqV). Ranks were attributed to the number of structures visualized from the posterior pole towards the periphery. The rank of FAF could then be analysed by Spearman’s correlation against age. Additionally, patients were divided by age into group 1 (< 40 weeks of corrected gestational age (WCGA)) and group 2 (> 40 WCGA). Differences between groups were tested with the Mann–Whitney U test. Thirteen patients were analysed. The mean WCGA at examination was 47.85 weeks. Spearman’s correlation showed a strong positive correlation (r = 0.714) (P = 0.006) of FAF and WCGA. The Mann–Whitney U test revealed that the PP/VA and EqV were significantly more visible at > 40 WCGA than at < 40 WCGA (8.0 [P = 0.016] and 7.5 [P = 0.03], respectively). Patterns of FAF are described for the first time in premature infants. FAF increases gradually with age and centrifugally from the posterior pole towards the equator in premature infants.

Optical Coherence Tomography Neuro-Toolbox for the Diagnosis and Management of Papilledema, Optic Disc Edema, and Pseudopapilledema

BACKGROUND

Distinguishing optic disc edema from pseudopapilledema is a common, sometimes challenging clinical problem. Advances in spectral-domain optical coherence tomography (SD-OCT) of the optic nerve head (ONH) has proven to be a cost effective, noninvasive, outpatient procedure that may help. At its core are tools that quantify the thickness of the retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GC-IPL). The SD-OCT also provides a set of tools that may be qualitatively interpreted in the same way that we read an MRI. They include the transverse axial, en face, and circular tomogram. Our goal is to describe a practical office-based set of tools using SD-OCT in the diagnosis and monitoring of papilledema, optic disc edema, and pseudopapilledema.

EVIDENCE ACQUISITION

Searches on PubMed were performed using combinations of the following key words: OCT, papilledema, pseudopapilledema, optic disc drusen, retinal folds (RF), and choroidal folds (CF).

RESULTS

The principal elements of SD-OCT analysis of the ONH are the RNFL and GC-IPL thickness; however, these metrics have limitations when swelling is severe. Qualitative interpretation of the transverse axial SD-OCT aids in assessing peripapillary shape that may help distinguish papilledema from pseudopapilledema, evaluate atypical optic neuropathies, diagnose shunt failures, and identify outer RF and CF. There is a consensus that the SD-OCT is the most sensitive way of identifying buried optic disc drusen. En face SD-OCT is especially effective at detecting peripapillary wrinkles and outer retinal creases, both of which are common and distinctive signs of optic disc edema that rule out pseudopapilledema. Mechanically stressing the ONH in the adducted eye position, in patients with papilledema, may expose folds and peripapillary deformations that may not be evident in primary position. We also discuss how to optimize the acquisition and registration of SD-OCT images.

CONCLUSIONS

The SD-OCT is not a substitute for a complete history and a careful examination. It is, however, a convenient ancillary test that aids in the diagnosis and management of papilledema, optic disc edema, and pseudopapilledema. It is particularly helpful in monitoring changes over the course of time and distinguishing low-grade papilledema from buried drusen. The application of the SD-OCT toolbox depends on optimizing the acquisition of images, understanding its limitations, recognizing common artifacts, and accurately interpreting images in the context of both history and clinical findings.

The role of clinical signs in the diagnosis of papilledema: development of an algorithm

PURPOSE

The aim of this study was not only to emphasize the role of clinical signs as well as ophthalmologic evaluation for accurate and differential diagnosis of papilledema (PE), but also to present an instructive algorithm that would help to eliminate unnecessary examinations and treatments.

METHOD

The files of 43 patients (ages 0-18) diagnosed with PE were retrospectively reviewed. The study included 25 patients from our pediatric neurology outpatient clinic, who were thought to have PE, and 18 patients, who were referred from the external centers to our hospital with a pre-diagnosis of PE.

RESULTS

Of the 43 patients, 28 had PE, 8 had pseudopapilledema (PPE), and 7 had optic nerve pathologies (ONP). For patients who applied directly to our pediatric neurology unit, a margin of error of 8% was detected based on only a simple ophthalmologic examination and an evaluation of clinical findings. For the patients who were forwarded to our pediatric neurology unit from the external centers without examining any clinical findings and with no details, the margin of error was 72%.

CONCLUSION

For patients with suspected PE, advanced ophthalmologic opinion is a necessary requirement before invasive radiological examinations are used. When the ophthalmologic evaluation is properly elaborated, the distinction can be made more clearly by using noninvasive methods. In order to determine the gold standard in terms of the methods used in the evaluation of patients who are not clinically diagnosed, new prospective studies with more patients should be planned.

Novice emergency physician ultrasonography of optic nerve sheath diameter compared to ophthalmologist fundoscopic evaluation for papilledema

OBJECTIVES

The purpose of this study is to determine the sensitivity and specificity of novice emergency physician-performed point-of-care ultrasound diagnosis of papilledema using optic nerve sheath diameter (ONSD) against ophthalmologist-performed dilated fundoscopy. This observational study retrospectively analyzed results of ultrasound-measured ONSD of emergency department (ED) patients with suspected intracranial hypertension from a period spanning June 2014 to October 2017.

METHODS

This study concerns a population of ED patients at a large, tertiary-care urban academic medical center from June 2014 to October 2017 over the age of 18 years with primary vision complaints evaluated for papilledema both by an emergency physician-performed ultrasound and an ophthalmologist-performed fundoscopic examination during their ED stay. Sensitivity and specificity of emergency physician-performed ultrasound measurement of optic nerve sheath diameter in the diagnosis of papilledema were primary outcomes for this study.

RESULTS

A total of 206 individual patients (male 49%, female 51%; median age 45 years) were included in the study with a total of 212 patient encounters. Calculated sensitivity for the ocular ultrasound examination performed by emergency physicians to diagnose papilledema was 46.9% (95% confidence interval [CI], 32.5% to 61.7%), and specificity was 87.0% (95% CI, 82.8% to 90.5%). Positive predictive value and negative predictive value were calculated to be 35.4% (95% CI, 23.9% to 48.2%) and 91.5% (95% CI, 87.8% to 94.4%), respectively.

CONCLUSIONS

Sonographic measurement of ONSD by emergency physicians has low sensitivity but high specificity for detection of papilledema compared to ophthalmologist-conducted fundoscopy.

Correlation between the total number of features of paediatric pseudotumour cerebri syndrome and cerebrospinal fluid pressure

PURPOSE

Accurate diagnosis of pseudotumour cerebri syndrome (PTCS) in children is challenging. We aimed to see if the clinical and radiological assessment that is carried out before lumbar puncture could predict subsequently recorded CSF pressures, and thus whether it could be used to increase diagnostic certainty of paediatric PTCS.

METHODS

We used internationally recognised diagnostic criteria to derive a list of clinical, brain neuroimaging and venography features that were accepted to be associated with a diagnosis of PTCS. We performed a retrospective cohort study of children referred to our centre with suspected PTCS, identifying the presence or absence of those features for each child at initial presentation. The sum total scores of the features that were present were correlated with the child's recorded CSF pressure.

RESULTS

The sum total scores were significantly positively correlated with recorded CSF pressures. The positive correlation was seen when clinical and brain neuroimaging features were included alone, and the correlation was slightly stronger when venography features were included in addition.

CONCLUSION

Calculating the sum total of clinical, brain neuroimaging and venography features (where venography is performed) present at initial presentation can help in the management of children under investigation for PTCS. Children with high scores are more likely to have severely raised CSF pressures and thus may warrant more urgent LP investigations. By contrast, in children with subtle abnormalities in optic disc appearance such that disc oedema cannot be ruled out, a low score may add further reassurance and less urgency to proceed to LP.

Peripapillary hyperreflective ovoid mass-like structures-a novel entity as frequent cause of pseudopapilloedema in children

BACKGROUND

Optic nerve head drusen (ONHD) are considered the most common cause for pseudopapilloedema in children. We aimed to investigate and further characterize a new type of optic nerve head lesion on enhanced depth imaging optical coherence tomography (EDI-OCT) named peripapillary hyperreflective ovoid mass-like structures (PHOMS), and ONHD in asymptomatic children with pseudopapilloedema.

METHODS

Retrospective cohort study including 64 eyes from 32 patients with pseudopapilloedema due to PHOMS and/or ONHD. Mean age was 9.0 ± 3.1 years. PHOMS and ONHD were identified and classified on EDI-OCT and infrared images. Ultrasound images were classified for the presence of hyperechogenic structures of the optic nerve head.

RESULTS

On EDI-OCT, PHOMS were detected in 63 out of 64 eyes (98.4%). In 60 eyes (93.8%), small hyperreflective foci inside the PHOMS were present. In all cases, we identified a new ring sign visible on infrared images, corresponding clearly to the edge of the PHOMS as seen on EDI-OCT. On ultrasound, we describe a new feature of PHOMS appearing as small hyperechogenic structures without posterior shadowing. In 13 eyes (20.3%), ONHD were present on EDI-OCT and ultrasound.

CONCLUSION

This is the first study showing that PHOMS are the most common cause for pseudopapilloedema in children. PHOMS is a new entity of optic nerve head lesions. It might be a precursor of buried optic nerve head drusen, which can lead to visual field defects, haemorrhages and CNV. This study offers new tools to identify and follow-up these lesions early in childhood using EDI-OCT.

Optic disc drusen: a systematic review : Up-to-date and future perspective

BACKGROUND

Optic disc drusen (ODD) are acellular deposits in the prelaminar optic nerve head. The most accredited theory is that they are secondary to abnormalities in axonal metabolism and degeneration, but the pathogenesis is not clear to date.

CLINICAL MANIFESTATION

Although ODD are often considered a benign condition, the great majority of patients with ODD show visual field defects and are at higher risk for developing anterior ischemic optic neuropathy. ODD are classified as superficial or buried, with the latter being often misdiagnosed as papilledema with optic nerve head swelling, leading to an unnecessary investigation for causes of increased intracranial pressure.

AIM

The recent technological improvements in OCT imaging which allowed an earlier and more certain diagnosis even of the smallest ODD, renovated the interest around this pathology. However, an updated systematic review is still missing. Therefore, the aim of this work is to provide a concise yet comprehensive overview of the current state of art, focusing on pathophysiology, clinical presentation, diagnostic methods, treatment modalities and potential future perspectives of this condition.

Imaging Methods for Differentiating Pediatric Papilledema from Pseudopapilledema: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the accuracy of ophthalmic imaging methods to differentiate between papilledema and pseudopapilledema in children.

METHODS

Literature searches were conducted in January 2020 in the PubMed database for English-language studies with no date restrictions and in the Cochrane Library database without any restrictions. The combined searches yielded 354 abstracts, of which 17 were reviewed in full text. Six of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. All 6 included studies were rated as level III evidence.

RESULTS

Fluorescein angiography, a combination of 2 OCT protocols, and multicolor confocal scanning laser ophthalmoscopy (Spectralis SD-OCT; Heidelberg Engineering, Heidelberg, Germany) demonstrated the highest positive percent agreement (92%-100%; 95% confidence interval [CI], 69%-100%) and negative percent agreement (92%-100%; 95% CI, 70%-100%) with a clinical diagnosis of papilledema in children. However, results must be interpreted with caution owing to methodologic limitations, including a small sample size leading to wide CIs and an overall lack of data (there was only 1 study each for the above methods and protocols). Ultrasonographic measures showed either a high positive percent agreement (up to 95%) with low negative percent agreement (as low as 58%) or vice versa. Autofluorescence and fundus photography showed a lower positive (40%-60%) and negative (57%) percent agreement.

CONCLUSIONS

Although several imaging methods demonstrated high positive and negative percent agreement with clinical diagnosis, no ophthalmic imaging method conclusively differentiated papilledema from pseudopapilledema in children because of the lack of high-quality evidence. Clinicians must continue to conduct thorough history-taking and examination and make judicious use of ancillary testing to determine which children warrant further workup for papilledema.

Diagnostic Value of Systematic Imaging Examination in Embedded Optic Disc Drusen in Adolescents with Mild Visual Impairment

Aim

To evaluate the diagnostic value of systematic ophthalmologic imaging examination in the diagnosis of embedded optic disc drusen (ODD) in adolescents with mild visual impairment.

Methods

Eleven patients were evaluated through optometric examination, fundus photography, visual field inspection, optical coherence tomography (OCT), ultrasonography (US), and fundus fluorescein angiography (FFA). Of the 11 patients, three also underwent cranial and orbital magnetic resonance imaging (MRI).

Results

All 11 patients had either no apparent abnormality or only mild refractive abnormalities. In all patients, fundus inspection revealed flushing the optic disc with varying degrees of limited boundary ambiguity and optic disc congestion with disappearance of the fovea. One patient had a visual field defect during the period of edema of ODD, but the visual field returned to normal after the optic disc edema subsided. US revealed discoid acousto-optic masses in front of the optic disc in six patients. OCT showed a slight elevation and thinning of the retinal nerve fiber layer (RNFL) of the optic disc in all patients. Quasicircular, hyperreflex signals of different sizes could be observed below the RNFL. Late-stage FFA revealed focal staining at the edge of the optic disc without fluorescence leakage in all patients. Orbital and cranial MRI findings were normal in the three patients.

Conclusion

A systematic ophthalmologic imaging examination can not only improve the detection rate of embedded ODD but also avoid excessive examinations and treatments.

Equivalence of Oral Fluorescein Angiography to Intravenous Fluorescein Angiography in Evaluating Pediatric Optic Nerve Pathology

Differentiating true optic nerve edema from pseudo-optic nerve edema is a diagnostic dilemma faced by pediatric ophthalmologists. This case series suggests that oral fluorescein angiography is equivalent to intravenous fluorescein angiography in making this distinction. [J Pediatr Ophthalmol Strabismus. 2019;56:e68-e72.].

Enhanced Depth Imaging Optical Coherence Tomography of Optic Nerve Head Drusen in Children

BACKGROUND

To assess the utility of enhanced depth imaging optical coherence tomography (EDI-OCT), compared with other conventional imaging modalities, for detecting and characterizing optic nerve head drusen (ONHD) in children.

METHODS

We report a retrospective cross-sectional case series of consecutive pediatric patients (age ≤16 years) with ONHD confirmed using B-scan ultrasonography. All eyes were evaluated using spectral-domain OCT of the optic nerve head in conventional (non-EDI) and EDI modes, fundus autofluorescence (FAF), and standard automated perimetry. Detection rates and the capacity to characterize ONHD were compared between EDI-OCT, non-EDI-OCT, and FAF.

RESULTS

Twenty-eight eyes of 15 patients (mean age 11 years; 60% female) were identified with definite ONHD that were confirmed by B-scan ultrasound. Among the technologies, EDI-OCT, non-EDI-OCT, FAF, and automated perimetry had findings consistent with ONHD in 24, 21, 18, and 4 eyes, respectively. EDI-OCT had a significantly better detection capability (86% of eyes) compared with FAF (P = 0.04) but not with non-EDI-OCT (P = 0.15). Similar to results previously reported in adult patients, EDI-OCT detected ONHD at different levels of depth; most were located anterior to the lamina cribrosa. ONHD detected by EDI-OCT appeared as hypo-reflective ovoid regions bordered by hyper-reflective material or as isolated hyper-reflective bands without a hypo-reflective core. The mean greatest diameter of ONHD seen on EDI-OCT was 449.7 (SD ±114.1) μm.

CONCLUSIONS

EDI-OCT detects ONHD in most eyes identified as having drusen on B-scan ultrasonography. This technique has the potential to be an effective alternative first-line diagnostic and monitoring tool for ONHD, particularly for detecting buried drusen in children.

The Utility of Fundus Fluorescein Angiography in Neuro-Ophthalmology

While its use is still widespread within the medical retina field, fundus fluorescein angiography (FFA) is increasingly falling out of favour in the investigation of neuro-ophthalmological disease, with the introduction of new technologies, particularly optical coherence tomography. FFA does, however, provide useful diagnostic and prognostic information in many neuro-ophthalmological diseases including papilloedema, pseudo-papilloedema, optic neuropathies and central retinal artery occlusion to name a few. We aim to summarise the main FFA findings in each of these conditions and highlight where FFA is of most use in providing complementary information to other modes of investigation.

Don't Miss This! Red Flags in the Pediatric Eye Exam: Blurred Disc Margins

Evaluating a patient with blurred optic disc margins, particularly a child, and establishing a diagnosis can be a demanding task. We aim to review the differential diagnosis of blurred disc margins, identify the clinical characteristics of a swollen optic disc, discuss imaging modalities used in the evaluation of the optic nerve head as tools for formulating a diagnosis, and identify red flags that may indicate a serious disorder.

Optical coherence tomography in paediatric clinical practice

Optical coherence tomography is a non-invasive ocular imaging technique that is frequently used in the diagnosis and monitoring of optic nerve or retinal disease. Advances in optical coherence tomography speed and image processing capability allow increased use of the modality in clinical practice, especially in younger children. This review outlines the challenges involved in imaging children, highlights the technological progress, the importance of acquiring normative data and, finally, focuses on the clinical applicability of optical coherence tomography in our paediatric population with various ocular conditions.

Detection of Papilloedema Study (DOPS): rates of false positive papilloedema in the community

BACKGROUND

Overdiagnosis of papilloedema is common and carries significant potential for morbidity from over-investigation and over-treatment. We aimed to determine the community prevalence of false positive diagnosis of papilloedema (FPE) on fundus imaging.

METHODS

We evaluated fundus images from a community cross-section of 198 12-14-year-olds from the Avon Longitudinal Study of Parents and Children (ALSPAC) longitudinal cohort study database and patient images from our hospital departmental database with and without papilloedema. We asked clinicians, in isolation, to rate the subjects as a forced choice task to "papilloedema" or "not papilloedema" based on the fundus images alone. Raters comprised (i) four neuro-ophthalmologists, (ii) four ophthalmologists, (iii) four neurologists and (iv) four emergency medicine physicians.

RESULTS

The prevalence of FPE in the ALSPAC population, defined as images mistaken as papilloedema by χ% of raters (P_χ) varied from P₁₀₀ = 0% to P₅₀ = 21.3 ± 3.9%. In the hospital population, there was a lower rate of FPE, P₅₀ = 7.1 ± 10.8%. Sensitivity for papilloedema detection approached 100%, though three raters incorrectly labelled the same patient with unilateral disc swelling as normal, all other cases were detected by all raters.

CONCLUSIONS

Fundus photography assessment in isolation is highly sensitive but poorly specific for papilloedema detection. Using this method to screen the general population has significant potential for harm as overdiagnosis occurs, even in the hands of experienced clinicians.

Predictors of Primary Intracranial Hypertension in Children Using a Newly Suggested Opening Pressure Cutoff of 280 mm H2O

OBJECTIVES

We assessed the clinical characteristics of primary intracranial hypertension (PIH) in children using a newly recommended threshold for cerebrospinal fluid opening pressure (280 mm H₂O).

METHOD

Cross-sectional study of patients age ≤21 years who had a lumbar puncture done for evaluation of PIH. Patients were excluded if lumbar puncture was done for a suspected infection, seizure, mental status changes, multiple sclerosis, or Guillain-Barre syndrome. Cases were identified using a text-search module followed by manual review. We performed χ2 analysis for categorical data and Mann-Whitney U test for continuous data, followed by a binary logistic regression.

RESULTS

We identified 374 patients of whom 67% were female, median age was 13 years interquartile range (11 to 16 years), and admission rate was 24%. Using an opening pressure cutoff of 250 mm H₂O, 127 patients (34%) were identified as having PIH, whereas using the new cutoff 105 patients (28%) met PIH criteria. Predictors for PIH included optic disc edema or sixth nerve palsy using both old, odds ratio (OR) 7.6 (4.3, 13.5), and new cutoffs, OR 9.7 (95% confidence interval 5.1, 18.5). Headache duration ≤61 days is predictive of PIH using the new cutoff OR 4.1 (95% confidence interval 1.3, 12.8). A model is presented which stratifies patients into groups with low (7%), medium (18%), and high (greater than 42%) risk of PIH.

CONCLUSIONS

A higher cerebrospinal fluid opening pressure threshold in the criteria of PIH is associated with PIH patients with a different symptom profile. Children with optic disc edema, bulging fontanel or sixth nerve palsy, are at increased risk for PIH.

Optical Coherence Tomography Angiography in Papilledema Compared With Pseudopapilledema

Purpose

The purpose of this study is to evaluate differences in optical coherence tomography angiography (OCT-A) findings between patients with papilledema and pseudopapilledema.

Methods

In this prospective, comparative study, 41 eyes of 21 subjects with papilledema, 27 eyes of 15 subjects with pseudopapilledema, and 44 eyes of 44 healthy normal subjects were included and were imaged using OCT-A. In addition to peripapillary total vasculature maps obtained with commercial vessel density mapping, major vessel removal using customized image analysis software was also used to measure whole image capillary density and peripapillary capillary density (PCD). Peripapiilary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC) were recorded.

Results

Average RNFL thicknesses were greater in papilledema eyes than in pseudopapilledema and control subjects. GCC thickness was not different among three groups. Peripapillary vasculature values were significantly lower in papilledema (58.5 ± 6.1%) and pseudopapilledema (58.9 ± 4.7%) eyes compared with healthy eyes (63.2 ± 3.1%) using commercial machine software, without a difference between papilledema and pseudopapilledema eyes. However, using our customized software, peripapillary "capillary" density of papilledema eyes was 29.8 ± 9.4%, which was not significantly different from healthy subjects (31.8 ± 7.4%; P = 0.94). Pseudopapilledema eyes with peripapillary density of 25.5 ± 8.3% had significantly lower capillary values compared with control eyes (P = 0.01). There was a significantly lower whole image and nasal sector peripapillary capillary density of inner retina in pseudopapilledema eyes than papilledema eyes (P = 0.03 and P = 0.02, respectively).

Conclusions

Whole image and nasal peripapillary sector capillary densities using OCT-A had diagnostic accuracy for differentiating true and pseudo-disc swelling.

Optic Nerve Head Drusen: An Update

Optic nerve head drusen are benign acellular calcium concretions that usually form early in life, just anterior to the lamina cribrosa. Improving imaging using optical coherence tomography suggests they are common and may be present in many clinically normal discs. These drusen may change in appearance in early life, but are generally stable in adulthood, and may be associated with visual field defects, anterior ischaemic optic neuropathy, or rarer complications. Based on long-term clinical data and optical coherence tomography, we propose a refined hypothesis as to the cause of optic disc drusen. Here we summarise recent findings and suggest future studies to better understand the forces involved.

Intracranial hypertension: a current review

PURPOSE OF REVIEW

To provide a current review of recent publications with regards to intracranial hypertension.

RECENT FINDINGS

Attempts were made to provide pediatric data; however, the recent completion of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) has provided a wealth of data with regards to adult intracranial hypertension.The pediatric incidence of intracranial hypertension ranges between 0.63 and 0.71 per 100 000 children. A majority of pediatric cases responded to acetazolamide, with resolution of headache averaging 3.8 weeks. Most patients require less than 1 year of treatment with male sex, older age at diagnosis, primary intracranial hypertension, and lack of headache being predictors of good response. Fluorescein angiography has the highest accuracy in distinguishing true papilledema from pseudopapilledema. The IIHTT found Frisen grade of papilledema was within 1 grade in 92.8% of patients. Monitoring of potassium levels is not required and aplastic anemia was not seen in patients taking acetazolamide.

SUMMARY

Although the newer pediatric studies report incidence rates in pediatric intracranial hypertension are lower than seen in adults, intracranial hypertension is still a concern in pediatrics. There has been a wealth of information with regards to symptomatology, treatment, and outcomes from the IIHTT that will hopefully assist with management in the pediatric population.

Optical coherence tomography is a useful tool in the differentiation between true edema and pseudoedema of the optic disc

Purpose

To assess the usefulness of spectral-domain optical coherence tomography (SD-OCT) peripapillary retinal nerve fiber layer (RNFL) thickness measurement in discriminating early phase optic disc edema (ODE) from pseudoedema (PODE).

Methods

Hospital-based, multicenter, cross-sectional study involving external patients referred for recent identification of “presumed ODE”. Patients underwent SD-OCT optic nerve head (ONH) RNFL thickness measurement at their first evaluation. In 155 of these, the causative etiology was subsequently ascertained and the respective eyes (one per patient) were assigned to the ODE (95 eyes) or PODE (60 eyes) group. Admission SD-OCT data were retrieved and used for the analysis. ROC curve analysis was used to calculate specificity, sensitivity and predictive value (PV) of the RNFL values.

Results

The PODE group was significantly younger than the ODE group (p = 0.007). The average and any single-quadrant RNFL thickness was significantly higher in the ODE group compared with the PODE and control groups. The average and the inferior quadrant thicknesses tested the most powerful parameters to differentiate ODE from PODE. A cutoff value of ≥ 110 μm for the average area, or of ≥ 150 μm for the inferior quadrant was associated with maximal sensitivity and specificity with positive PV greater than 80%.

Conclusions

The SD-OCT evaluation of the peripapillary RNFL achieved good specificity, sensitivity and positive PV in discriminating between ODE and PODE. Despite the correct differential diagnosis between these categories still relies on a careful medical history taking and other ancillary testing, we proved the usefulness of SD-OCT RNFL measurement in supporting the diagnostic process.

Optic disc drusen: understanding an old problem from a new perspective

Optic disc drusen (ODD) are acellular deposits located in the optic nerve head of up to 2.4% of the population. They may develop as by-products of impaired axonal metabolism in genetically predisposed individuals, in whom a narrow scleral canal is hypothesized to play a role. Although ODD are often considered as benign innocent bystanders, recognized as part of a routine ophthalmological examination, the vast majority of patients with ODD have visual field defects. Optic disc drusen (ODD)-associated complications with severe visual loss, most often due to anterior ischaemic optic neuropathy, are also known to occur. There are no treatments available to prevent or ameliorate the vision loss caused by ODD. In children, the ODD are usually uncalcified and buried within the optic nerve head tissue. In these cases, the condition can be difficult to diagnose, as it often resembles a papilloedema with optic nerve head swelling caused by raised intracranial pressure. During the teenage years, the ODD progressively become more calcified and probably also larger, which allow them to be visible on ophthalmoscopy. With the advent and proper utilization of high-resolution modalities of optical coherence tomography (OCT), it has now become possible to detect even the smallest and most deeply located ODD. This allows for ODD detection at a much earlier developmental stage than has previously been possible and enhances the possibilities of research in underlying mechanisms. A review of the literature on ODD was conducted using the PUBMED database. The review focuses on the current knowledge regarding pathogenesis, diagnostics, clinical disease-tracking methodologies, structure-function relationships and treatment strategies of ODD.

The Role of Optical Coherence Tomography in the Acute Management of Neuro-Ophthalmic Diseases

Optical coherence tomography (OCT) can provide high-speed and high-resolution images of the anatomical structures of the optic nerve head and macula. However, in neuro-ophthalmic conditions that present acutely, structural changes lag functional deficits, and the role of OCT in the acute setting has been challenged. This review aims to summarize the recent literature and evidence supporting the use of OCT in the acute management of some common neuro-ophthalmic scenarios, including the differential diagnosis of optic disc swelling, and in patients with suspected papilledema, optic neuritis, ischemic optic neuropathies, and Leber hereditary optic neuropathy. The limitations of OCT are also discussed.