Imaging Methods for Differentiating Pediatric Papilledema from Pseudopapilledema

A Report by the American Academy of Ophthalmology


      To review the published literature on the accuracy of ophthalmic imaging methods to differentiate between papilledema and pseudopapilledema in children.


      Literature searches were conducted in January 2020 in the PubMed database for English-language studies with no date restrictions and in the Cochrane Library database without any restrictions. The combined searches yielded 354 abstracts, of which 17 were reviewed in full text. Six of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. All 6 included studies were rated as level III evidence.


      Fluorescein angiography, a combination of 2 OCT protocols, and multicolor confocal scanning laser ophthalmoscopy (Spectralis SD-OCT; Heidelberg Engineering, Heidelberg, Germany) demonstrated the highest positive percent agreement (92%–100%; 95% confidence interval [CI], 69%–100%) and negative percent agreement (92%–100%; 95% CI, 70%–100%) with a clinical diagnosis of papilledema in children. However, results must be interpreted with caution owing to methodologic limitations, including a small sample size leading to wide CIs and an overall lack of data (there was only 1 study each for the above methods and protocols). Ultrasonographic measures showed either a high positive percent agreement (up to 95%) with low negative percent agreement (as low as 58%) or vice versa. Autofluorescence and fundus photography showed a lower positive (40%–60%) and negative (57%) percent agreement.


      Although several imaging methods demonstrated high positive and negative percent agreement with clinical diagnosis, no ophthalmic imaging method conclusively differentiated papilledema from pseudopapilledema in children because of the lack of high-quality evidence. Clinicians must continue to conduct thorough history-taking and examination and make judicious use of ancillary testing to determine which children warrant further workup for papilledema.

      Abbreviations and Acronyms:

      CI (confidence interval), cSLO (confocal scanning laser ophthalmoscopy), EDI (enhanced depth imaging), ODD (optic disc drusen), RNFL (retinal nerve fiber layer), SD (spectral-domain)
      To read this article in full you will need to make a payment


      Subscribe to Ophthalmology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Leon M.
        • Hutchinson A.K.
        • Lenhart P.D.
        • Lambert S.R.
        The cost-effectiveness of different strategies to evaluate optic disk drusen in children.
        J AAPOS. 2014; 18: 449-452
        • Martinez M.R.
        • Ophir A.
        Optical coherence tomography as an adjunctive tool for diagnosing papilledema in young patients.
        J Pediatr Ophthalmol Strabismus. 2011; 48: 174-181
        • Thompson A.C.
        • Bhatti M.T.
        • El-Dairi M.A.
        Bruch’s membrane opening on optical coherence tomography in pediatric papilledema and pseudopapilledema.
        J AAPOS. 2018; 22: 38-43 e33
        • Chang M.Y.
        • Velez F.G.
        • Demer J.L.
        • et al.
        Accuracy of diagnostic imaging modalities for classifying pediatric eyes as papilledema versus pseudopapilledema.
        Ophthalmology. 2017; 124: 1839-1848
        • Chang M.Y.
        • Pineles S.L.
        Optic disk drusen in children.
        Surv Ophthalmol. 2016; 61: 745-758
        • Kurz-Levin M.M.
        • Landau K.
        A comparison of imaging techniques for diagnosing drusen of the optic nerve head.
        Arch Ophthalmol. 1999; 117: 1045-1049
        • Pineles S.L.
        • Arnold A.C.
        Fluorescein angiographic identification of optic disc drusen with and without optic disc edema.
        J Neuroophthalmol. 2012; 32: 17-22
        • Malmqvist L.
        • Li X.Q.
        • Eckmann C.L.
        • et al.
        Optic disc drusen in children: the Copenhagen Child Cohort 2000 Eye Study.
        J Neuroophthalmol. 2018; 38: 140-146
        • Merchant K.Y.
        • Su D.
        • Park S.C.
        • et al.
        Enhanced depth imaging optical coherence tomography of optic nerve head drusen.
        Ophthalmology. 2013; 120: 1409-1414
        • Silverman A.L.
        • Tatham A.J.
        • Medeiros F.A.
        • Weinreb R.N.
        Assessment of optic nerve head drusen using enhanced depth imaging and swept source optical coherence tomography.
        J Neuroophthalmol. 2014; 34: 198-205
        • Malmqvist L.
        • Lindberg A.W.
        • Dahl V.A.
        • et al.
        Quantitatively measured anatomic location and volume of optic disc drusen: an enhanced depth imaging optical coherence tomography study.
        Invest Ophthalmol Vis Sci. 2017; 58: 2491-2497
        • Malmqvist L.
        • Bursztyn L.
        • Costello F.
        • et al.
        The Optic Disc Drusen Studies Consortium recommendations for diagnosis of optic disc drusen using optical coherence tomography.
        J Neuroophthalmol. 2018; 38: 299-307
        • Kupersmith M.J.
        • Sibony P.
        • Mandel G.
        • et al.
        Optical coherence tomography of the swollen optic nerve head: deformation of the peripapillary retinal pigment epithelium layer in papilledema.
        Invest Ophthalmol Vis Sci. 2011; 52: 6558-6564
        • Tan A.C.
        • Fleckenstein M.
        • Schmitz-Valckenberg S.
        • Holz F.G.
        Clinical application of multicolor imaging technology.
        Ophthalmologica. 2016; 236: 8-18
        • Oxford Centre for Evidence-Based Medicine
        Levels of evidence. March 2009.
        (Accessed 02.06.17)
        • Food and Drug Administration Center for Devices and Radiological Health
        Statistical guidance on reporting results from studies evaluating diagnostic tests.
        (2007 Accessed 28.10.19)
        • Neudorfer M.
        • Ben-Haim M.S.
        • Leibovitch I.
        • Kesler A.
        The efficacy of optic nerve ultrasonography for differentiating papilloedema from pseudopapilloedema in eyes with swollen optic discs.
        Acta Ophthalmol. 2013; 91: 376-380
        • Malem A.
        • De Salvo G.
        • West S.
        Use of MultiColor imaging in the assessment of suspected papilledema in 20 consecutive children.
        J AAPOS. 2016; 20: 532-536
        • Dahlmann-Noor A.H.
        • Adams G.W.
        • Daniel M.C.
        • et al.
        Detecting optic nerve head swelling on ultrasound and optical coherence tomography in children and young people: an observational study.
        Br J Ophthalmol. 2018; 102: 318-322
        • Hayreh S.S.
        Pathogenesis of optic disc edema in raised intracranial pressure.
        Prog Retin Eye Res. 2016; 50: 108-144
        • Leung C.K.
        • Ye C.
        • Weinreb R.N.
        • et al.
        Retinal nerve fiber layer imaging with spectral-domain optical coherence tomography a study on diagnostic agreement with Heidelberg Retinal Tomograph.
        Ophthalmology. 2010; 117: 267-274
        • Tsikata E.
        • Verticchio Vercellin A.C.
        • et al.
        Volumetric measurement of optic nerve head drusen using swept-source optical coherence tomography.
        J Glaucoma. 2017; 26: 798-804