Can point-of-care handheld Optical Coherence Tomography (OCT) differentiate early papilledema from pseudopapilledema in children under 5 years, compared to Magnetic Resonance Imaging (MRI) and fundoscopy?

From the Guidelines

Handheld optical coherence tomography (OCT) devices should not be used as a standalone diagnostic tool for differentiating early papilledema from pseudopapilledema in children under 5 years, due to limited evidence and technical challenges. The diagnostic accuracy of handheld OCT devices compared to MRI and fundoscopy in very young children remains limited by several factors, including the smaller anatomical structures in pediatric eyes and the difficulty in obtaining high-quality images due to lack of cooperation from young children 1. MRI remains the gold standard for identifying underlying causes of papilledema, such as intracranial masses or hydrocephalus, and can provide a higher resolution of intracranial and intraorbital structures compared to CT scans 1. The reusable handheld OCT devices offer advantages in pediatric settings, including portability, no need for sedation, and potential for serial monitoring, but should be used as a complementary tool rather than a replacement for conventional diagnostic methods. For accurate diagnosis in children under 5, a multimodal approach combining clinical examination, fundoscopy, and neuroimaging remains necessary, with handheld OCT serving as a potentially valuable adjunct technology. Some key markers for distinguishing true disc edema from pseudopapilledema, such as retinal nerve fiber layer thickness and optic disc elevation, can be visualized using handheld OCT devices, but the results should be interpreted with caution and in conjunction with other diagnostic modalities 1. In cases where papilledema or signs of raised intracranial pressure are suspected, MRI of the head and orbits with and without IV contrast is usually the most appropriate initial imaging modality, as it can provide a comprehensive evaluation of the intracranial and intraorbital structures 1.

From the Research

Diagnostic Accuracy of Point of Care Handheld OCT

• The diagnostic accuracy of point of care handheld OCT in differentiating early papilledema from pseudopapilledema in children under 5 years is not directly addressed in the provided studies.
• However, a study published in 2021 2 found that optical coherence tomography (OCT) features, such as circumpapillary retinal nerve fiber layer (cpRNFL) thickness, can help differentiate between papilledema and pseudopapilledema in children.
• The study found that a cpRNFL thickness of ≥140 µm demonstrated a sensitivity of 83% and specificity of 76% for identifying papilledema.

Comparison with MRI and Fundoscopy

• A study published in 2020 3 reviewed the literature on the accuracy of ophthalmic imaging methods, including OCT, in differentiating between papilledema and pseudopapilledema in children.
• The study found that OCT, as well as other imaging methods such as fluorescein angiography and multicolor confocal scanning laser ophthalmoscopy, demonstrated high positive and negative percent agreement with clinical diagnosis.
• However, the study noted that the results must be interpreted with caution due to methodologic limitations, including small sample sizes and a lack of high-quality evidence.
• Another study published in 2021 2 found that the combination of B-scan ultrasonography (BSUS) and OCT features, such as optic nerve sheath widening and cpRNFL thickness, can improve the diagnostic accuracy for differentiating between papilledema and pseudopapilledema.
• The study found that the presence of both optic nerve sheath widening (>4.5 mm) and cpRNFL thickness of ≥140 µm reduced the sensitivity but increased the specificity for identifying papilledema.

Limitations and Future Directions

• The provided studies highlight the challenges in differentiating between papilledema and pseudopapilledema in children, and the need for further research to establish the diagnostic accuracy of point of care handheld OCT in this population.
• A study published in 2017 4 noted that missing true papilledema can result in life-threatening or vision-threatening consequences, and emphasized the importance of accurate diagnosis and timely treatment.
• Another study published in 2025 5 highlighted the importance of joint care between ophthalmologists and neurologists in treating the underlying condition and managing any visual dysfunction and headache associated with papilledema.