The usefulness of multimodal imaging for differentiating pseudopapilloedema and true swelling of the optic nerve head: a review and case series

Abstract

Ophthalmic practitioners have to make a critical differential diagnosis in cases of an elevated optic nerve head. They have to discriminate between pseudopapilloedema (benign elevation of the optic nerve head) and true swelling of the optic nerve head. This decision has significant implications for appropriate patient management. Assessment of the optic disc prior to the advanced imaging techniques that are available today (particularly spectral domain optical coherence tomography and fundus autofluorescence), has mainly used diagnostic tools, such as funduscopy and retinal photography. As these traditional methods rely on the subjective assessment by the clinician, evaluation of the elevated optic nerve head to differentiate pseudopapilloedema from true swelling of the optic nerve head can be a challenge in clinical practice with patients typically referred for further neuroimaging investigation when the diagnosis is uncertain. The use of multimodal ocular imaging tools such as spectral domain optical coherence tomography, short wavelength fundus autofluorescence and ultrasonography, can potentially aid in the differentiation of pseudopapilloedema from true swelling of the optic nerve head, in conjunction with other clinical findings. By doing so, unnecessary patient costs and anxiety in the case of pseudopapilloedema can be reduced, and appropriate urgent referral and management in the case of true swelling of the optic nerve head can be initiated.

Differentiation between optic disc drusen and optic disc oedema using fundus photography

“…This prevalence gap implies that visualization of ODD on fundus examination could not be enough to detect hidden buried ODD. Calcification could be detected by B-scan ultrasound or computed tomography (Kurz-Levin & Landau 1999;Neudorfer et al 2013;Chiang et al 2015). Unfortunately, a B-scan ultrasound failed to show signs of ODD in more than half the eyes with suspicion of buried ODD (Kurz-Levin & Landau 1999).…”

Volumetric Measurement of Optic Nerve Head Drusen Using Swept-Source Optical Coherence Tomography

“…Classically, ultrasound is considered the most sensitive means of diagnosis, but the low resolution of ultrasound biomicroscopy (30 microns at 50 MHz ultrasonic frequency) 9 is insufficient to evaluate drusen structure and progression. Commercially available spectral-domain optical coherence tomography (SD-OCT) instruments have been used to qualitatively describe the appearance of drusen 10-12 and to distinguish ONHD from papilledema, 6-8, 13-15 but they are limited to measurements of RNFL thinning and ganglion cell layer thinning, neither of which is specific to ONHD. 16,17 Enhanced depth imaging (EDI) OCT and swept source (SS) OCT have also enabled qualitative descriptions of ONHD.…”

The value of visual field testing in the era of advanced imaging: clinical and psychophysical perspectives

“…Because of this, optic neuropathies such as optic neuritis, neuroretinitis and optic nerve head drusen may all present with different visual field defects. 59,[143][144][145] Therefore, (Table 1, patient E). The fundus examination showed a small disc with clear optic nerve head cupping, superior and inferior neuroretinal rim thinning and retinal nerve fibre layer (RNFL) drop out.…”

“…In comparison to glaucoma and other ischaemic optic neuropathies, other optic diseases, such as inflammatory or compressive neuropathies, can affect different regions of the optic nerve and retinal nerve fibre layer and to varying degrees. Because of this, optic neuropathies such as optic neuritis, neuroretinitis and optic nerve head drusen may all present with different visual field defects . Therefore, unlike glaucoma, these conditions sometimes do not have obvious structure‐function concordance, unless the region of optic nerve affected by disease is discrete, such as in optic disc pit (Figure ).…”

“…Cirrus RNFL analysis showed thinning of the adjacent RNFL bundles superiorly, inferiorly and nasally (G). Autofluorescence imaging (Spectralis OCT) showed hyperautofluorescence of the optic nerve, especially in the nasal aspect, characteristic of buried optic nerve head drusen (H), with corresponding hyper‐reflective material on the coronal scan (I, yellow arrows) . Although the RNFL appeared reduced superiorly, nasally and inferiorly, the HFA 30–2 SITA‐Standard result showed only an inferonasal depression (J).…”