Imaging Methods for Differentiating Pediatric Papilledema from Pseudopapilledema OTA

A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Pediatric Ophthalmology/Strabismus Panel

Melinda Y. Chang, MD,¹ Gil Binenbaum, MD, MSCE,² Gena Heidary, MD, PhD,³ David G. Morrison, MD,⁴ Jennifer A. Galvin, MD,⁵ Rupal H. Trivedi, MD, MSCR,⁶ Stacy L. Pineles, MD⁷ 

Ophthalmology, October 2020, Vol 127, 1416-1423 © 2020 by the American Academy of Ophthalmology. Click here for free access to this OTA. 

Purpose: To review the published literature on the accuracy of ophthalmic imaging methods to differentiate between papilledema and pseudopapilledema in children.

Methods: Literature searches were conducted in January 2020 in the PubMed database for English-language studies with no date restrictions and in the Cochrane Library database without any restrictions. The combined searches yielded 354 abstracts, of which 17 were reviewed in full text. Six of these were considered appropriate for inclusion in this assessment and were assigned to a level of evidence rating by the panel methodologist. All 6 included studies were rated as level III evidence.

Results: Fluorescein angiography, a combination of 2 OCT protocols, and multicolor confocal scanning laser ophthalmoscopy (Spectralis SD-OCT; Heidelberg Engineering, Heidelberg, Germany) demonstrated the highest positive percent agreement (92%-100%; 95% confidence interval [CI], 69%-100%) and negative percent agreement (92%-100%; 95% CI, 70%-100%) with a clinical diagnosis of papilledema in children. However, results must be interpreted with caution owing to methodologic limitations, including a small sample size leading to wide CIs and an overall lack of data (there was only 1 study each for the above methods and protocols). Ultrasonographic measures showed either a high positive percent agreement (up to 95%) with low negative percent agreement (as low as 58%) or vice versa. Autofluorescence and fundus photography showed a laser positive (40%-60%) and negative (57%) percent agreement.

Conclusions: Although several imaging methods demonstrated high positive and negative percent agreement with clinical diagnosis, no ophthalmic imaging method conclusively differentiated papilledema from pseudopapilledema in children because of the lack of high-quality evidence. Clinicians must continue to conduct thorough history-taking and examination and make judicious use of ancillary testing to determine which children warrant further workup for papilledema.

¹Children's Hospital of Los Angeles, Roski Eye Institute, University of Southern California, Los Angeles, California

²Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

³Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts

⁴Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee

⁵Eye Physicians and Surgeons PC, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut

⁶Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina

⁷Stein Eye Institute, University of California, Los Angeles, California