Impact of the COVID-19 pandemic and Honey Rose case on hospital attendances of patients suspected to have papilloedema

The Increasing Burden of Emergency Department and Inpatient Consultations for "Papilledema"

BACKGROUND

Increasing incidence of idiopathic intracranial hypertension (IIH), overreported radiologic signs of intracranial hypertension, difficult access to outpatient neuro-ophthalmology services, poor insurance coverage, and medicolegal concerns have lowered the threshold for emergency department (ED) visits for "papilledema." Our objective was to examine referral patterns and outcomes of neuro-ophthalmology ED and inpatient consultations for concern for papilledema.

METHODS

At one university-based quaternary care center, all adults referred for "papilledema" over one year underwent a standardized ED "papilledema protocol." We collected patient demographics, final diagnoses, and referral patterns.

RESULTS

Over 1 year, 153 consecutive patients were referred for concern for papilledema. After papilledema protocol, 89 of 153 patients (58%) had bilateral optic disc edema, among whom 89% (79/89) had papilledema (intracranial hypertension). Of the 38 of 153 (25%) consultations for suspected disorder of intracranial pressure without previous fundus examination (Group 1), 74% (28/38) did not have optic disc edema, 21% (8/38) had papilledema, and 5% (2/38) had other causes of bilateral disc edema. Of the 89 of 153 (58%) consultations for presumed papilledema seen on fundus examination (Group 2), 58% (66/89) had confirmed papilledema, 17% (15/89) had pseudopapilledema, and 9% (8/89) had other causes of bilateral optic disc edema. Of the 26 of 153 (17%) patients with known IIH (Group 3), 5 had papilledema and 4 required urgent intervention. The most common diagnosis was IIH (58/79). Compared with IIH, patients with secondary causes of intracranial hypertension were older (P = 0.002), men (P < 0.001), not obese (P < 0.001), and more likely to have neurologic symptoms (P = 0.002).

CONCLUSION

Inpatient and ED consultations for "papilledema" are increasing. Of the 153 ED and inpatient neuro-ophthalmology consultations seen for "papilledema" over 1 year, one-third of patients with optic disc edema of unknown cause before presentation to our ED had new vision- or life-threatening disease, supporting the need for prompt identification and evaluation of optic disc edema in the ED. In the face of limited access to neuro-ophthalmologists, this study supports the need for emergency department access to expert eye-care evaluation or ocular fundus camera for prompt identification of optic disc edema and standardized evaluation for neurologic emergencies.

The BONSAI (Brain and Optic Nerve Study with Artificial Intelligence) deep learning system can accurately identify pediatric papilledema on standard ocular fundus photographs

BACKGROUND

Pediatric papilledema often reflects an underlying severe neurologic disorder and may be difficult to appreciate, especially in young children. Ocular fundus photographs are easy to obtain even in young children and in nonophthalmology settings. The aim of our study was to ascertain whether an improved deep-learning system (DLS), previously validated in adults, can accurately identify papilledema and other optic disk abnormalities in children.

METHODS

The DLS was tested on mydriatic fundus photographs obtained in a multiethnic pediatric population (<17 years) from three centers (Atlanta-USA; Bucharest-Romania; Singapore). The DLS's multiclass classification accuracy (ie, normal optic disk, papilledema, disks with other abnormality) was calculated, and the DLS's performance to specifically detect papilledema and normal disks was evaluated in a one-vs-rest strategy using the AUC, sensitivity and specificity, with reference to expert neuro-ophthalmologists.

RESULTS

External testing was performed on 898 fundus photographs: 447 patients; mean age, 10.33 (231 patients ≤10 years of age; 216, 11-16 years); 558 normal disks, 254 papilledema, 86 other disk abnormalities. Overall multiclass accuracy of the DLS was 89.6% (range, 87.8%-91.6%). The DLS successfully distinguished "normal" from "abnormal" optic disks (AUC 0.99 [0.98-0.99]; sensitivity, 87.3% [84.9%-89.8%]; specificity, 98.5% [97.6%-99.6%]), and "papilledema" from "normal and other" (AUC 0.99 [0.98-1.0]; sensitivity, 98.0% [96.8%-99.4%]; specificity, 94.1% (92.4%-95.9%)].

CONCLUSIONS

Our DLS reliably distinguished papilledema from normal optic disks and other disk abnormalities in children, suggesting it could be utilized as a diagnostic aid for the assessment of optic nerve head appearance in the pediatric age group.

Eyecare practitioner perspectives and attitudes towards myopia and myopia management in the UK

OBJECTIVE

Many children with progressive myopia are still prescribed single-vision correction. An investigation into UK eyecare practitioners' (ECPs) perceptions of myopia management was carried out to ascertain factors which may be limiting its implementation and uptake within clinical practice.

METHODS AND ANALYSIS

Online focus groups were held with UK ECPs. Participants were encouraged to discuss their knowledge of the available myopia management options, their perception of how myopia management is being delivered in the UK and any barriers limiting ECPs' prescribing of these management options in practice. The discussions were transcribed and analysed thematically.

RESULTS

Focus groups were held with 41 ECPs from primary and secondary eyecare. ECPs felt that provision of myopia management in the UK is variable. Most ECPs believe they have sufficient knowledge, but felt a lack of confidence in decision-making and practical experience. Less experienced ECPs sought more definitive guidance to support their decision-making. ECPs desired clarity on their duty of care obligations and were concerned over possible future litigation if they had not offered, or referred for, myopia management when indicated. The greatest barrier appears to be financial-treatment is expensive and ECPs are uncomfortable communicating this to parents. Many barriers were indicative of systemic problems within UK eyecare, such as commercial pressures, inadequate National Health Service funding and poor public awareness of paediatric eyecare.

CONCLUSION

Myopia management is not implemented consistently across the UK. To improve accessibility, changes are required at multiple levels, from individual ECPs through to wider stakeholders in UK eyecare provision.