Non-Invasive Detection of Recurrent Intracranial Pressure via Optical Coherence Tomography: A Case Report

BACKGROUND Papilledema is a common sign of increased intracranial pressure (ICP). However, detecting relapse of increased ICP is difficult because once optic nerve atrophy is present, re-swelling of the optic nerve head is not expected to be visible on fundoscopy. CASE REPORT This report describes the case of a 23-year-old woman with a ventriculoperitoneal shunt implanted at the age of 11 years due to idiopathic hydrocephalus presenting swelling of the peripapillary nerve fiber layer (pRNFL) on optical coherence tomography (OCT) without visible papilledema. She had been having headaches, nausea, and visual acuity deterioration. A neurological examination and fundus evaluation of both eyes showed pallor of the optic nerves without clinically visible disc edema, and magnetic resonance imaging (MRI) of the head did not reveal any signs of increased intracranial pressure. In the following days, after bilateral abducens nerve palsy occurred, a lumbar puncture removing cerebrospinal fluid was performed to temporarily reduce ICP. After the procedure, all her symptoms were resolved, visual acuity improved, and pRNFL swelling was reduced. CONCLUSIONS Optical coherence tomography is a quick, non-invasive, sensitive, and objective in vivo method for monitoring recurrence of increased ICP and treatment response. Therefore, OCT should be performed in all patients suspected to have high ICP when an ophthalmological examination does not reveal papilledema, especially in all cases with optic atrophy.