Oral fluorescein angiography cannot always distinguish papilledema from pseudopapilledema

Many imaging modalities are used to differentiate papilledema from pseudopapilledema in children, but to date there have been few data published focusing on the effectiveness of oral fluorescein angiography (OFA) for this purpose.

Study design

Investigators conducted a retrospective evaluation of records of 45 children and adolescents aged 6–18 years who underwent OFA for suspected optic disc swelling at a children’s hospital between May 2018 and August 2021. Eleven patients had papilledema and 34 had pseudopapilledema. Evaluation of OFA was completed by 2 masked examiners comparing the images to those of standard OFA images of optic nerve disorder from either idiopathic intracranial hypertension or optic nerve head drusen (ONHD) with grading on the Frisen scale of 0–5. The images were interpreted as having full optic disc leakage, borderline leakage, or no leakage.

Outcomes

The accuracy of OFA ranged from 62% to 69%. Each reviewer correctly noted leakage of OFA in 9 of 11 patients with papilledema, but incorrectly interpreted no leakage in 2 patients with papilledema with mild optic disc edema (grade 1–2 on the Frisen scale). No patients had evidence of visible ONHD.

Limitations

Many of the patients in this cohort had mild optic disc edema, which was associated with a reduced accuracy of the OFA as reported by the masked examiners.

Clinical significance

The clinical evaluation of the optic disc is very valuable in pediatric ophthalmology. This study is the largest cohort to date examining OFA accuracy of mild optic disc swelling by masked examiners. While the authors note that OFA was found to be a feasible and relatively safe option in their study (compared with more invasive modalities, such as intravenous fluorescein angiography), it cannot be used alone as a diagnostic tool to distinguish papilledema from pseudopapilledema.

Financial disclosures: Dr. Jennifer Galvin discloses no financial relationships.