How to identify papilloedema and pseudopapilloedema, as well as what to do when you do, was the focus of a workshop led by optometrist and optical engagement manager at the Brian Tumour Charity, Lorcan Butler, at the AOP’s Locum clinical skills conference last year (Birmingham, 5 November).
Butler opened by highlighting the general identifiable markers for those who may present with papilloedema , which he summarised to OT as “a condition where the optic nerve is swollen, and usually in the presence of elevated intercranial pressure.”
“It can be a sight-threatening and life-threatening condition that effects both children and adults,” he emphasised.
Butler explained that 90% of patients will be symptomatic, 90% will be female, 90% will be obese, and 90% will come from a low socio-economic background.
Touching on the difference between papilloedema and pseudopapilloedema , the optometrist explained that pseudopapilloedema “is where the optic nerve appears to be swollen, but it’s actually not, so it tends to be a physiological variation. And usually it’s congenital – people are born with it.”
Butler highlighted that papilloedema is easy to spot with optical coherence tomography (OCT). He advised practitioners without access to OCT to test the optic nerve.
“If there is nerve function, that’s very reassuring. If there is nerve dysfunction, that would be a concern,” he said.
Explaining how to test the optic nerve without an OCT, Butler highlighted three key tests: colour vision, the pupils, and visual fields.
“This test suite is what we refer to as testing the nerve function. If there is nerve disfunction you will probably have an anonymous result in one or all three of those tests,” Butler said.
Highlighting that papilloedema can be found in both adults and children, Butler informed delegates that approximately 50% of children with papilloedema will have a visual field defect. He added that the key question to ask children with suspect papilloedema is: does your vision ever disappear?
Butler shared that the quality of life for patients with papilloedema “is really poor.”
“They have debilitating headaches,” the optometrist said, sharing that they are often described as sharp intense, acute, painful and throbbing.
Butler emphasised that optometrists who suspect papilloedema in a patient should refer urgently, on the same day.
“College of Optometrist Guidelines stipulate an urgent referral on same day,” Butler said. “We need to refer to ophthalmology, to casualty, to A&E, and we have a duty of care to look after our patients to the best of our ability, so that needs to be done the same day,” he added.
When referring, Butler encouraged, “we stay in our own lane,” by referring to ophthalmology.
“We would never refer to neurology, and we would never refer to neuro-ophthalmology,” he said, explaining that specificity can limit the referral choices and delay the referral.
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