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Clinical approach for suspected optic disc swelling in children: recommendations based on a six-year review
1Department of Ophthalmology, Queensland Children's Hospital, Brisbane, Queensland, Australia.
Insights
In children, suspected optic disc swelling is often pseudopapilloedema. Early ophthalmic review with specific tests can differentiate true swelling from pseudopapilloedema, avoiding unnecessary neuroimaging.
Area of Science:
- Ophthalmology
- Pediatrics
- Neurology
Background:
- Suspected optic disc swelling is a frequent pediatric presentation.
- Differentiating true optic disc swelling from pseudopapilloedema is crucial for appropriate management.
- A streamlined diagnostic pathway is needed to prevent unnecessary investigations.
Purpose of the Study:
- To investigate the outcomes of referrals for suspected optic disc swelling in children.
- To identify features aiding in the investigation and diagnosis of optic disc swelling.
- To reduce unnecessary neuroimaging in pediatric patients with suspected optic disc swelling.
Main Methods:
- Retrospective review of pediatric referrals for optic disc swelling.
- Data collected from Queensland Children's Hospital between January 2014 and June 2020.
- Analysis of patient demographics, clinical findings, diagnostic tests, and outcomes.
Main Results:
- Out of 410 referrals, 66 confirmed optic disc swelling and 344 had pseudopapilloedema.
- Idiopathic intracranial hypertension was the most common cause of true optic disc swelling (n=25).
- Optic disc drusen (n=239) and crowded/tilted discs (n=105) were the main causes of pseudopapilloedema.
- Headache (OR=8.68) and visual disturbance (OR=2.14) were more common in true optic disc swelling.
- B-scan ultrasound showed 100% sensitivity for optic disc drusen detection.
- Retinal nerve fibre layer thickness was significantly greater in true optic disc swelling (p<0.01).
Conclusions:
- Pseudopapilloedema is more common than true optic disc swelling in pediatric referrals.
- Referrals should incorporate neurological assessment, visual acuity, fundus photography, and optical coherence tomography.
- Neuroimaging before ophthalmology review is discouraged for children without neurological symptoms.
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.
