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Accuracy of Diagnostic Imaging Modalities for Classifying Pediatric Eyes as Papilledema Versus Pseudopapilledema
Melinda Y Chang1, Federico G Velez2, Joseph L Demer3
1Department of Ophthalmology, University of California, Los Angeles, Los Angeles, California; Stein Eye Institute, University of California, Los Angeles, Los Angeles, California; Doheny Eye Institute, University of California, Los Angeles, Los Angeles, California.
Insights
Fluorescein angiography (FA) is the most accurate imaging method for diagnosing papilledema (PE) in children. Other techniques have a high misinterpretation rate, potentially delaying critical treatment for elevated intracranial pressure.
Area of Science:
- Ophthalmology
- Pediatric Imaging
- Neuro-ophthalmology
Background:
- Accurate differentiation between papilledema (PE) and pseudopapilledema (PPE) is crucial in pediatric patients.
- Misdiagnosis can lead to delayed treatment of serious underlying conditions like elevated intracranial pressure.
Purpose of the Study:
- To determine the most accurate diagnostic imaging modality for classifying pediatric eyes as PE or PPE.
- To compare the accuracy and misinterpretation rates of various imaging techniques.
Main Methods:
- Prospective observational study of 19 children (5-18 years) with confirmed PE or PPE.
- Utilized B-scan ultrasonography, fundus photography, autofluorescence, fluorescein angiography (FA), and optical coherence tomography (OCT) including RNFL and optic nerve head volumetric scans.
- Images were interpreted by masked neuro-ophthalmologists, with comparisons to clinical diagnoses.
Main Results:
- Fluorescein angiography (FA) demonstrated the highest accuracy (97%) in classifying PE versus PPE.
- FA revealed optic nerve leakage in PE, absence of hyperfluorescence in buried optic disc drusen (ODD), and nodular staining in superficial ODD.
- Other imaging modalities showed significant misinterpretation rates (30%-70%) of PE as PPE when used alone.
Conclusions:
- Fluorescein angiography (FA) is the optimal imaging technique for differentiating pediatric PE from PPE.
- Relying on other modalities in isolation increases the risk of misinterpreting PE as PPE.
- Accurate diagnosis via FA is vital to avoid missing sight- or life-threatening conditions associated with elevated intracranial pressure.
Purpose:
To identify the most accurate diagnostic imaging modality for classifying pediatric eyes as papilledema (PE) or pseudopapilledema (PPE).
Design:
Prospective observational study.
Subjects:
Nineteen children between the ages of 5 and 18 years were recruited. Five children (10 eyes) with PE, 11 children (19 eyes) with PPE owing to suspected buried optic disc drusen (ODD), and 3 children (6 eyes) with PPE owing to superficial ODD were included.
Methods:
All subjects underwent imaging with B-scan ultrasonography, fundus photography, autofluorescence, fluorescein angiography (FA), optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL), and volumetric OCT scans through the optic nerve head with standard spectral-domain (SD OCT) and enhanced depth imaging (EDI OCT) settings. Images were read by 3 masked neuro-ophthalmologists, and the final image interpretation was based on 2 of 3 reads. Image interpretations were compared with clinical diagnosis to calculate accuracy and misinterpretation rates of each imaging modality.
Main Outcome Measures:
Accuracy of each imaging technique for classifying eyes as PE or PPE, and misinterpretation rates of each imaging modality for PE and PPE.
Results:
Fluorescein angiography had the highest accuracy (97%, 34 of 35 eyes, 95% confidence interval 92%-100%) for classifying an eye as PE or PPE. FA of eyes with PE showed leakage of the optic nerve, whereas eyes with suspected buried ODD demonstrated no hyperfluorescence, and eyes with superficial ODD showed nodular staining. Other modalities had substantial likelihood (30%-70%) of misinterpretation of PE as PPE.
Conclusions:
The best imaging technique for correctly classifying pediatric eyes as PPE or PE is FA. Other imaging modalities, if used in isolation, are more likely to lead to misinterpretation of PE as PPE, which could potentially result in failure to identify a life-threatening disorder causing elevated intracranial pressure and papilledema.
