Diagnosis and Imaging of Optic Nerve Head Drusen

Retro-mode imaging for the diagnosis of optic disc drusen: a case series

OBJECTIVE

We aimed to compare the detectability of optic disc drusen (ODD), using various non-invasive imaging techniques, including the novel retro-mode imaging (RMI), as well as to analyze the morphological characteristics of ODD on RMI.

METHODS

This study involved seven patients with bilateral ODD, totaling 14 eyes. Multimodal imaging techniques, including multicolor fundus photography (MC), near-infrared reflectance (NIR), green and blue light fundus autofluorescence (G-FAF and B-FAF, respectively), and RMI were used to examine the eyes. FAF was used as the primary method of identifying ODD, and each method's detection rate was compared by two observers. Quantitative measurements of ODD included the number of ODD visualized by the RMI technique, the perimeter (P) and area (A) of ODD were identified.

RESULTS

The average age of the patients included was 49.28 ± 23.16 years, with five of the seven being men. RMI was able to detect ODD in all cases, with a sensitivity of 100%, compared to MC (sensitivity 60.71%), NIR (sensitivity 60.71%), B-FAF (sensitivity 100%), G-FAF (sensitivity 100%). RMI was the only imaging technique capable of assessing ODD morphology and quantifying ODD.

CONCLUSIONS

RMI is a promising imaging modality for diagnosing superficial ODD, providing valuable information on the distribution, location, and size of ODD. We suggest the incorporation of RMI as a complementary tool for diagnosing and monitoring ODD in combination with other multimodal imaging methods.

Concomitant optic disk drusen and papilledema due to idiopathic intracranial hypertension in a pediatric cohort

BACKGROUND

Optic disk drusen (ODD) in pediatric patients typically presents with pseudopapilledema. Diagnosing concomitant papilledema due to idiopathic intracranial hypertension (IIH) in these patients can be challenging. The purpose of this study was to evaluate the incidence and clinical features of papilledema due to IIH among pediatric patients with a new diagnosis of ODD and to discuss the clinical and paraclinical findings that helped diagnose this group.

METHODS

The medical records of children <15 years of age with ODD confirmed by B-scan ultrasound at their first visit over a 4-year period (2019-2022) were reviewed retrospectively. Patients with concurrent IIH were identified, and the demographic and clinical characteristics were reviewed.

RESULTS

A total of 83 children with confirmed ODD at the initial presentation were included, of whom 4 (4.8%) were diagnosed with concomitant IIH. Patients ranged in age from 7 to 15 years; 3 of the 4 were female, and 3 had IIH-related symptoms at presentation (1 was asymptomatic). None of the 4 patients had papilledema greater than Frisen grade 2.

CONCLUSIONS

We recommend that clinicians review pertinent IIH symptoms and risk factors in children with ODD and follow the standard workup for IIH in suspicious cases. In asymptomatic patients with a new diagnosis of ODD, we recommend obtaining a follow-up optic nerve evaluation and optical coherence tomography scan to detect any significant interval change that might serve as a possible indicator of concomitant papilledema.

The Presence of Optic Disc Drusen in Eyes with Uveitis

PURPOSE

To evaluate the coexistence of optic disc drusen (ODD) in eyes with uveitis.

METHODS

In this retrospective, observational study, patients followed up in a uvea clinic with all types of uveitis were evaluated. ODD were confirmed by ocular ultrasonography, optic nerve head enhanced-depth imaging optical coherence tomography, fundus autofluorescence, and fundus photography.

RESULTS

ODD were detected in 17 of 545 (3.1%) uveitis patients. The mean age was 18.9 ± 10.4 years, and 76.5% were female. 45.5% were anterior, 42.4% were panuveitis, 6.1% were intermediate, and 6.1% were posterior uveitis. ODD were found bilaterally in all 17 patients; uveitis was unilateral in one patient. 58.8% were under the age of 18, and in this group, the rate of buried ODD was 78.9% (p = 0.039). In adults (seven patients), ODD were buried in 42.9%.

CONCLUSION

ODD can be detected in eyes with uveitis and may clinically mimic optic disc edema, lead to misdiagnosis and/or overtreatment.

Optic nerve sheath diameter and axial length in patients with optic disc drusen: a cross-sectional study

AIM

Measuring the optic nerve sheath diameter (ONSD) and the anteroposterior axial length of the eye in patients with optic disc drusen (ODD).

METHODS

A total of 43 healthy volunteers and 41 patients with ODD were included in the study. The ONSD and axial length were measured in the posterior position using an ultrasound device (E-Z Scan AB5500 +) probe with a 10 MHz frequency. The ONSD was measured 3 mm behind the globe wall. Receiver operating characteristic (ROC) curve analysis was performed to determine patients with ODD using ONSD. Any p-value of < 0.05 was accepted to demonstrate significance.

RESULTS

The ONSD was significantly higher (5.2 mm and 4.8 mm, p = 0.006, respectively), and the axial length was shorter (21.82 ± 2.15 mm and 23.27 ± 1.96 mm, p = 0.002, respectively) in the ODD group. The spherical equivalent was more commonly seen as hypermetropic in the ODD group (1.00 [- 0.85 to 1.75]). In the ROC analysis to determine the ONSD value in ODD diagnosis, the area under the curve was 0.6754 (95% confidence interval 0.559-0.788, p = 0.006). ONSD cutoff of 5.70 mm had a sensitivity of 0.366 and a specificity of 0.907 to diagnose ODD.

CONCLUSION

In this study, the ONSD was significantly higher in the ODD group. The axial length was shorter in the ODD group. This study is the first in the literature to evaluate the ONSD in patients with optic disc drusen. Further studies are needed in this regard.

Discriminating Between Papilledema and Optic Disc Drusen Using 3D Structural Analysis of the Optic Nerve Head

BACKGROUND AND OBJECTIVES

The distinction of papilledema from other optic nerve head (ONH) lesions mimicking papilledema, such as optic disc drusen (ODD), can be difficult in clinical practice. We aimed the following: (1) to develop a deep learning algorithm to automatically identify major structures of the ONH in 3-dimensional (3D) optical coherence tomography (OCT) scans and (2) to exploit such information to robustly differentiate among ODD, papilledema, and healthy ONHs.

METHODS

This was a cross-sectional comparative study of patients from 3 sites (Singapore, Denmark, and Australia) with confirmed ODD, those with papilledema due to raised intracranial pressure, and healthy controls. Raster scans of the ONH were acquired using OCT imaging and then processed to improve deep-tissue visibility. First, a deep learning algorithm was developed to identify major ONH tissues and ODD regions. The performance of our algorithm was assessed using the Dice coefficient. Second, a classification algorithm (random forest) was designed to perform 3-class classifications (1: ODD, 2: papilledema, and 3: healthy ONHs) strictly from their drusen and prelamina swelling scores (calculated from the segmentations). To assess performance, we reported the area under the receiver operating characteristic curve for each class.

RESULTS

A total of 241 patients (256 imaged ONHs, including 105 ODD, 51 papilledema, and 100 healthy ONHs) were retrospectively included in this study. Using OCT images of the ONH, our segmentation algorithm was able to isolate neural and connective tissues and ODD regions/conglomerates whenever present. This was confirmed by an averaged Dice coefficient of 0.93 ± 0.03 on the test set, corresponding to good segmentation performance. Classification was achieved with high AUCs, that is, 0.99 ± 0.001 for the detection of ODD, 0.99 ± 0.005 for the detection of papilledema, and 0.98 ± 0.01 for the detection of healthy ONHs.

DISCUSSION

Our artificial intelligence approach can discriminate ODD from papilledema, strictly using a single OCT scan of the ONH. Our classification performance was very good in the studied population, with the caveat that validation in a much larger population is warranted. Our approach may have the potential to establish OCT imaging as one of the mainstays of diagnostic imaging for ONH disorders in neuro-ophthalmology, in addition to fundus photography.

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.

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 Nerve Drusen Is Highly Prevalent Among Children With Pseudotumor Cerebri Syndrome

Introduction: The clinical presentation of pseudotumor cerebri syndrome (PTCS) usually includes headache, nausea, and vomiting with normal physical examination apart from papilledema and diplopia. However, pseudopapilledema, which can be caused by optic nerve drusen, may lead to misdiagnosis. The prevalence of optic nerve drusen in the general population is 0.5–2%. The purpose of our study was to evaluate the prevalence and risk factors of optic nerve drusen among patients with PTCS.

Materials and Methods: Medical records of children evaluated in the pediatric department at Bnai Zion Medical Center due to PTCS between 2008 and 2020 were assessed. Inclusion criteria were children age under 18 years with a PTCS diagnosis and ophthalmic B-mode ultrasonography (US). Exclusion criteria were secondary intracranial hypertension.

Results: Thirty-four children were included with a mean age 10.1 years which included 50% boys. A majority of the patients, 24 (72.4%), complained of headaches, while 15 (45.5%) complained of transient visual obscuration, and 9 (26.5%) of vomiting. Visual acuity on presentation was normal (20/20–20/30) in 23 of the children (67%), moderately diminished (20/40–20/80) in 9 (26%), and showing profound loss (20/200) in 2 (7%). Five patients (14.7%) were diagnosed with optic nerve drusen via B-mode ophthalmic ultrasonography (US). However, they still fulfilled the diagnostic criteria for PTCS, and disc swelling improved after treatment. There were no statistically significant differences between the group with optic nerve drusen and the rest of the patients.

Conclusions: Optic nerve drusen are common among pediatric patients with PTCS. Diagnosis of optic nerve drusen should not rule out the presence of increased intracranial pressure.

Optic disc drusen mimicking Idiopathic Intracranial Hypertension (IIH): rely on ultrasound

Optic nerve ultrasound is an established routine supplementary diagnostic tool for idiopathic intracranial pressure but it can also be helpful in avoiding misdiagnoses. We describe a case of an obese 15- year-old girl with persistent headaches, fundoscopic findings suggesting papilledema, normal brain imaging who underwent two lumbar punctures with unremarkable cerebrospinal fluid findings before ultrasound revealed optic disc drusen as the cause of the optic disc elevation.

Microvascular alterations in children with optic disk drusen evaluated by optical coherence tomography angiography

PURPOSE

To asses changes in vessel density (VD) in children with optic disk drusen (ODD) using swept source optical coherence tomography angiography (OCTA).

METHODS

Cross-sectional study of 27 eyes with ODD compared with age-matched controls. Peripapillary and macular VD were measured in the superficial retinal capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC). The correlation between VD changes with alterations in retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and visual field (VF) was analyzed.

RESULTS

Mean participant age was 12.5 ± 3.3 years (range, 7-18 years); 63% was females. In the patients vs. controls, median central peripapillary VD was 52.9% vs. 50.6% (p = 0.63) for SCP; 48.1% vs. 53.8% (p = 0.017) for DCP; and 17.0% vs. 28.2% (p = 0.0037) for CC, respectively. VD in the superior and nasal CC layers was significantly lower in the patients (36.3% vs. 56.2%; p < 0.001) and (60.4% vs. 70.3%, p < 0.001), respectively. No significant differences were observed for VD in the macular region. The RNFL was thinner in eyes with superficial drusen versus controls (87 vs. 111 μm; p < 0.001). No significant differences between were observed in GCL thickness (p = 0.13). Nasal SCP and nasal RNFL VD were moderately correlated (r = 0.54, p < 0.01), while mean VF deviation was strongly correlated with median SCP VD in patients with superficial drusen (r = 0.9, p = 0.03).

CONCLUSION

Impaired VD was observed in the peripapillary nasal CC in patients with ODD; this impairment was associated with a decreased RNFL thickness. Nasal SCP VD and RNFL thickness were moderately correlated in patients with ODD.

Coexistence of idiopathic intracranial hypertension and optic disc drusen in a latin american patient: case report

Optic nerve drusen are acellular concretions of calcium located in the parenchyma of the optical nerve head described as the most common cause of pseudo-papilloedema, which makes it difficult to differentiate from a true optical disc oedema. Despite it being rare, the drusen of the optic nerve and the papilloedema secondary to idiopathic intracranial hypertension can coexist in the same patient. The case is presented of a 34 year-old woman referred to the Ophthalmology Department with visual discomfort, headaches, and pulsatile tinnitus of two months onset. In the physical examination there was bilateral blurring of the optic disc margin with absence of spontaneous venous pulsation. The diagnosis of idiopathic intracranial hypertension was made by lumbar puncture with the measurement of the opening pressure, and due to the findings of the magnetic resonance scan of the brain and the eye sockets. The optic nerve drusen was an incidental finding in an optical coherence tomography angiography, which would later be confirmed with an eye ultrasound. To our knowledge, this the first case reported in Latin America of the coexistence of optic nerve drusen and papilloedema secondary to idiopathic intracranial hypertension.

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.

Optic Coherence Tomography Angiography Findings of Bilateral Choroidal Neovascularization Associated with Optic Disc Drusen Treated with Intravitreal Aflibercept Injection

Purpose

The purpose of this case report is to present the findings of optical coherence tomography angiography (OCTA) of a patient with bilateral choroidal neovascularization (CNV) associated with optic disc drusen (ODD), who was treated with intravitreal aflibercept injection. Case presentation. A 14-year-old girl presented with a complaint of visual loss and metamorphopsia in her both eyes. Best-corrected visual acuity (BCVA) was 20/32 and 20/25, respectively, in the right and left eyes. Intraocular pressure and anterior segment examination were normal. Dilated fundus examination revealed elevated optic discs with blurred margins in both eyes. In addition, slightly elevated yellow lesion extending from optic nerve head to the macula was observed bilaterally. The patient underwent imaging with colour fundus photography, fundus autofluorescence (FAF), fundus fluorescein angiography (FFA), spectral-domain optic coherence tomography (SD-OCT), OCTA, orbital ultrasonography (USG), and computed tomography (CT). In particular, OCTA demonstrated clearly the large circular CNV complex in the right eye and the CNV structure in the left eye containing slightly activated main trunk and minimal vessel loops in the papillomacular region. CNV secondary to bilateral ODD was suspected. Intravitreal aflibercept injections were performed in 3 doses to the right eye and a single dose to the left eye. After the injections, BCVA reached its complete level in both eyes. SD-OCT revealed irregularity of RPE in the temporal region of the optic disc and complete regression of the subretinal fluid. Interestingly, the entire CNV complex including the main trunk completely disappeared in OCTA. CNV complex was not observed in OCTA during 1-year follow-up, and peripapillary and macular vascular density measurements did not show any significant change. BCVA was preserved, and no additional injections were needed.

Conclusion

It is possible that OCTA can be used for detailed evaluation of CNV associated with ODD, response to anti-VEGF treatment, and peripapillary and macular vascular density. There is a need for further studies to confirm the changes such as disappearance of CNV in OCTA after injection as we observed in our patient.