Paton’s Folds revisited: wrinkles, folds and creases in papilledema

Abstract

Purpose : In 1911 Paton and Holmes^{1, 2} made several observations about folds in papilledema (“Patons folds”), which included an assertion that the folds described by histopathology are the same as those seen by ophthalmoscopy. Using spectral domain optical coherence tomography (SDOCT) and photos we examined the peripapillary folds in patients with papilledema to correlate the OCT findings with funduscopic appearances.

Methods : We examined SD-OCT and photos of the optic nerve from 125 study eyes enrolled in the Idiopathic Intracranial Hypertension Treatment Trial OCT Substudy for peripapillary folds. We correlated en face and axial raster images with fundus photos to determine if we could relate Paton’s folds to those that we have previously reported.³

Results : The folds described histopathologically correspond to outer retinal folds(ORF) on OCT. They consist of widely spaced undulations often associated with subretinal fluid. Occasionally, they appear as small vertical lines which are deeply furrowed creases in the outer retina. Ophthalmoscopically, creases appear as hypopigmented lines commonly referred to as “high water marks”.ORF/creases should be distinguished from Paton’s ophthalmoscopic folds which consist of fine, closely spaced , peripapillary wrinkles (PPW) located temporally in the retinal nerve fiber layer (RNFL), usually concentric or spiral to the optic disc.³ ORF/creases were found in 20% of the study eyes at baseline, 9% at 3 months and 4% at 6 months. PPW were found in 46% of the study eyes at baseline. Both were significantly associated with a higher mean Frisén grade, RNFL thickness and optic disc volume but not with vision or intracranial pressure.

Conclusions : This report shows that Paton² actually described two types of peripapillary folds in papilledema: PPW and ORF/creases. PPW are located in the RNFL. ORF/creases can be distinguished by their location in the retina, greyish lines or peripapillary hypopigmented lines in photos, and creases on the OCT. In all , there are four types of folds in papilledema: PPW, inner retinal folds, choroidal folds (which we have previously described³) and ORF/creases. Retinal folds and wrinkles of papilledema are the structural manifestations of specific types of stress induced by intracranial pressure on both the optic disc and load bearing structures of the eye.

1.Paton, L. Brain 1911; 33:389
2.Paton L. Arch Ophthal 1936;15:1
3.Sibony PA. IOVS 2015;56:5670

This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.