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Swelling of Atrophic Optic Discs in Idiopathic Intracranial Hypertension
TAKE-HOME MESSAGE
- This retrospective study investigated the detection of papilledema recurrence in patients with idiopathic intracranial hypertension using optical coherence tomography. Notably, peripapillary retinal nerve fiber layer thickness was comparable between eyes with moderate and severe optic disc atrophy.
- Optical coherence tomography may be a useful imaging modality for detecting papilledema recurrence, even in eyes with severe optic disc atrophy.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Monitoring patients with idiopathic intracranial hypertension (IIH) and optic atrophy may be difficult as papilledema may not be appreciable on ophthalmoscopy. This retrospective chart review evaluated whether papilledema recurrence can be detected in this population using optical coherence tomography (OCT).
METHODS
Serial clinical assessments, ophthalmoscopy, and peripapillary OCT were reviewed in a cohort of patients with IIH and optic atrophy. Atrophy was defined as moderate if average peripapillary retinal nerve fiber layer (pRNFL) thickness was ≤80 μm and severe if average pRNFL thickness was ≤60 μm on at least 2 consecutive high-quality OCT scans. Based on the upper tolerance limit of test-retest variability, mean pRNFL elevation of ≥6 μm with subsequent decrease to baseline thickness was considered papilledema.
RESULTS
In a cohort of 165 patients with IIH, 32 eyes of 20 patients and 22 eyes of 12 patients demonstrated moderate and severe optic atrophy, respectively. Over a median follow-up of 198.5 weeks (range, 14.0-428.9), 63.3% (19 of 30) of patients had at least 1 episode of relapse, and 50.0% (15 of 30) had at least 1 episode of papilledema. There was a total of 36 relapse episodes, of which 7 occurred in patients with clinical signs and symptoms but no OCT evidence of relapse, 12 occurred in patients with OCT changes but no clinical signs and symptoms of relapse, and 17 occurred in patients with both clinical and OCT evidence to support relapse. The median percent pRNFL increase in the latter 2 groups was 13.7% (range, 7.5-111.8), and 7 eyes (13.0%) of 5 patients (16.7%) showed thickening greater than 20.0% from baseline. The rate, magnitude, and concordance of pRNFL swelling were similar between moderately vs severely atrophic eyes.
CONCLUSIONS
Papilledema recurrence can be detected in atrophic optic discs using OCT. All patients with atrophic IIH should be longitudinally monitored with pRNFL measurement. Concurrence of other relapse-suggestive features should prompt further evaluation.
Additional Info
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Swelling of Atrophic Optic Discs in Idiopathic Intracranial Hypertension
J Neuroophthalmol 2024 Jun 01;44(2)212-218, JS Xie, L Donaldson, EA MargolinFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The authors retrospectively analyzed a small dataset of patients with atrophic papilledema secondary to idiopathic intracranial hypertension to determine whether optical coherence tomography (OCT) is an effective tool for detecting relapse.
The authors grouped patients into moderate and severe optic atrophy cohorts and assessed symptoms of relapse along with changes in peripapillary retinal nerve fiber layer (pRNFL) edema. A larger proportion of patients with relapse showed increased pRNFL edema along with clinical symptomatology, with relapse being defined as an increase of at least 6 microns in mean pRNFL thickness. The median percentage increase in pRNFL thickness in patients with or without clinical symptomatology was 13.7%, with 5 patients showing an increase of greater than 20% from baseline. There were no differences in the increase in pRNFL thickness between the moderate and severe optic atrophy cohorts.
Although OCT has proven extremely useful in monitoring the response to treatment and relapse of chronic papilledema, it has been generally accepted that it has limited use in patients with optic atrophy owing to the inability of atrophic nerves to demonstrate appreciable swelling. Therefore, patient symptomatology has been one of the key determinants of relapse; however, this poses limitations given the fact that many patients with chronic intracranial hypertension are asymptomatic. Weight loss also guides the process by which clinicians can begin considering the tapering of medications, and OCT plays a crucial role in measuring the response to medication tapering. Unfortunately, the amount of weight loss that results in remission varies from patient to patient, underscoring the need for precise, objective measures to determine relapse. The bottom line is that without the ability to objectively and noninvasively diagnose idiopathic intracranial hypertension recurrence, there is a reluctance to wean patients from medical therapy, especially those who have significant visual compromise that could potentially worsen if treatment is disrupted.
Although the sample size in this study was not ideal for formulating conclusive recommendations, a tool with the potential to objectively determine relapse rates in this difficult-to-manage population is a welcome addition to addressing the challenges of managing chronic atrophic papilledema. The authors also suggest that the percentage of changes rather than raw changes in the pRNFL thickness should be utilized in patient monitoring and that symptoms and visual field results should also be considered in the determination of relapse.