Comparing true papilledema and pseudo-papilledema. a. This 19-year-old female was referred for evaluation of headaches and swollen optic nerves. Ultrasound ultimately disclosed buried optic nerve drusen. b. This 17-year-old male with lupus was also referred for evaluation of headaches and swollen optic nerves. Neuro-imaging was normal and lumbar puncture revealed an elevated opening pressure, and the patient was diagnosed with idiopathic intracranial hypertension. Although the optic nerve in the first photo appears elevated, it has smooth borders and an anomalous branching pattern. None of the vessels are obscured as they cross the border of the optic nerve, the blood vessels are not dilated, and there are no hemorrhages, exudates, or cotton-wool spots. By contrast, the borders of the swollen optic nerve are jagged, the peripapillary nerve fiber layer is splayed, and the blood vessels are dilated. If one looks closely, one will also observe that at least 3 vessels are obscured by edema as they cross over the border from the retina into the optic nerve.