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Diagnostic Utility of Paton's Folds and Quantitative OCT Metrics in Pediatric Papilledema
Jonathan Zhou1, Raj Vadhul2, David Rogers3
1The Ohio State University College of Medicine, Columbus, Ohio.
Insights
Peripapillary wrinkling (PPW) is specific for diagnosing papilledema in children, while retinal nerve fiber layer thickness and optic nerve head volume offer objective diagnostic thresholds. Spectral-domain optical coherence tomography aids in distinguishing these conditions.
Area of Science:
- Ophthalmology
- Pediatric Ophthalmology
- Medical Imaging
Background:
- Distinguishing papilledema from pseudopapilledema in pediatric patients is clinically significant.
- Spectral-domain optical coherence tomography (SD-OCT) offers high-resolution imaging of optic nerve head structures.
Purpose of the Study:
- To evaluate the diagnostic accuracy of peripapillary retinal folds (RF) and peripapillary wrinkling (PPW) using SD-OCT in pediatric papilledema versus pseudopapilledema.
- To determine optimal diagnostic thresholds for retinal nerve fiber layer (RNFL) thickness and optic nerve head volume (ONHV).
Main Methods:
- Retrospective cross-sectional study including pediatric patients with papilledema and pseudopapilledema.
- Two masked ophthalmologists independently reviewed transverse and en-face SD-OCT images for RF and PPW.
- RNFL thickness and ONHV were measured; Receiver Operator Curve (ROC) analysis determined diagnostic thresholds.
Main Results:
- RF or PPW were observed in 90.2% of papilledema eyes versus 38.6% of pseudopapilledema eyes (p < 0.0001).
- PPW showed high specificity (92.9%), while RF had higher sensitivity (79.2%).
- Optimal thresholds: RNFL ≥163 μm (AUC=0.908) and ONHV ≥5.43 mm³ (AUC=0.855) demonstrated high diagnostic accuracy.
Conclusions:
- Peripapillary wrinkling (PPW) is a specific indicator for pediatric papilledema.
- RNFL thickness and ONHV provide objective, discriminative thresholds for diagnosis.
- Integrating SD-OCT findings with clinical data enhances diagnostic confidence for pediatric papilledema.
Purpose:
We evaluated the diagnostic accuracy of peripapillary retinal folds (RFs) and peripapillary wrinkling (PPW) in distinguishing papilledema (PE) from pseudopapilledema (PPE) in pediatric patients using spectral-domain OCT (SD-OCT). We also identified diagnostic threshold values for retinal nerve fiber layer (RNFL) thickness and optic nerve head volume (ONHV).
Design:
Single-center, hospital and clinic-based, retrospective, cross-sectional study.
Participants:
We included 84 eyes from 42 pediatric patients with PE and 92 eyes from 46 pediatric patients with PPE.
Methods:
Two masked ophthalmologists (H.V. and D.R.) independently reviewed transverse and en face SD-OCT images to assess for RF and PPW. We manually segmented retinal layers and measured RNFL thickness and ONHV. We performed receiver operating curve (ROC) analysis with area under the curve (AUC) to determine optimal diagnostic thresholds. We assessed inter-rater reliability using Cohen's kappa.
Main Outcome Measures:
Sensitivity and specificity for RF and PPW; optimal diagnostic thresholds for RNFL and ONHV in distinguishing PE from PPE in pediatric patients.
Results:
We observed RFs or PPW in 90.2% of PE eyes and 38.6% of PPE eyes (P < 0.0001). Retinal folds demonstrated higher sensitivity (79.2%) but lower specificity (67.4%), whereas PPW showed higher specificity (92.9%) and lower sensitivity (43.5%) in distinguishing PE from PPE in pediatric patients. Transverse OCT had the highest probability of detecting RFs as a marker for PE, whereas en face OCT was more reliable at detecting PPW. Receiver operating characteristic analysis identified optimal PE screening thresholds of ≥163 μm for RNFL (AUC = 0.908) with 78% sensitivity and 93% specificity and a threshold of ≥5.43 mm3 for ONHV (AUC = 0.855) with 73% sensitivity and 90% specificity. Inter-rater agreement was higher for RF on transverse OCT (κ = 0.61) and higher for PPW on en face OCT (κ = 0.54).
Conclusions:
Peripapillary wrinkling is specific to PE in pediatric patients and an excellent rule-in tool. Transverse SD-OCT reliably detects Paton's folds, particularly RF. However, the limited specificity of RF and higher inter-rater variability of rare, subtle findings underscore the importance of incorporating quantitative OCT metrics. Retinal nerve fiber layer thickness and ONHV offer strong discriminative power and objective thresholds to support clinical decision-making. In borderline cases, clinicians can improve diagnostic confidence by integrating fold detection with RNFL and ONHV analysis, additional ancillary testing, and clinical history with exam to create a more accurate, noninvasive approach to distinguish PE from PPE in children.
Financial Disclosure(S):
Proprietary or commercial disclosure may be found after the references.
