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Rachel E Reem, David L Rogers; Initial visual acuity in pediatric patients presenting with severe papilledema. Invest. Ophthalmol. Vis. Sci. 2014;55(13):5102.
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© ARVO (1962-2015); The Authors (2016-present)
To evaluate initial visual acuity and background characteristics of pediatric patients presenting to a tertiary care center eye clinic with severe papilledema
A retrospective review of patients with elevated intracranial pressure, seen at a tertiary care center eye clinic from June 2008 to November 2013, was performed
Of 152 pediatric patients with confirmed intracranial hypertension, 8 presented with 4+ papilledema (Frisen scale). 6 of these patients were female, and 2 male. Age at diagnosis ranged from 3.9 years to 18.6 years (mean 13.4). Body Mass Index ranged from 14.2 to 50.7 (mean 32.6). Opening pressure on initial lumbar puncture was elevated in all cases and ranged from 32cm H2O to 65cm H2O (mean 45.4). Symptom duration, whether headache or diplopia, was 4 weeks or less in all but one patient. Six patients were able to participate in Humphrey visual field testing and all demonstrated visual field defects. Four patients had enlarged blind spots and the remaining 2 had dense superior altitudinal defects. Visual acuity was 20/25 or better in 8 of 14 eyes (one patient was too young/uncooperative to read the Snellen chart); the remaining 6 eyes were 20/30, 20/50, 20/60, 20/60, 20/80, and 20/200. Of the 4 eyes with 20/60 or worse visual acuity, 3 were noted to have subretinal fluid in the macula on funduscopic examination. After treatment and resolution of symptoms, 4 patients were left with residual enlarged blind spots on follow-up Humphrey visual field testing.
Of the 8 patients observed, 4 had visual acuity of 20/30 or better, in spite of having severe papilledema. All patients able to participate in visual field testing demonstrated field defects, and 4/6 patients were left with residual defects after treatment of intracranial hypertension. Finally, nearly all patients had had symptoms of short duration. This further supports the hypothesis that loss of central visual acuity is a later consequence of papilledema, even in patients who present initially with severe edema. We encourage clinicians to utilize visual field testing whenever possible when monitoring pediatric patients with papilledema. Solely relying on central visual acuity as an indication of optic nerve health can be misleading and result in permanent visual loss in this population.
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