Section

Investigation and referral guidelines for optometrists


Domains: Clinical practice, Communication

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Papilloedema is swelling of the optic nerves at the back of both eyes caused by raised intracranial pressure. Papilloedema is significant because it can be the first sign of life-threatening disease, eg brain tumours, hydrocephalus, cerebral venous sinus thrombosis. But the diagnosis of papilloedema can be difficult. It takes training to recognise papilloedema and interpret the results of specialist imaging tests, like optical coherence tomography (OCT), which help distinguish papilloedema from conditions which mimic it. 


While OCT is a great clinical tool to aid optic disc assessment in community optometry practice, it can also lead to many unnecessary referrals without the necessary training to interpret the results correctly. It is important that optometrists maintain their clinical skills in history taking and examination techniques, and do not lose sight of more traditional methods to assess optic discs accurately in conjunction with the patient’s symptoms.

This recorded lecture covers the following points:

  • Clinical symptoms of serious neurological diseases that cause headache and/or papilloedema
  • Differential diagnosis of the more common causes of unilateral/bilateral optic disc swelling and pseudopapilloedema
  • Optic disc examination:
    • Indirect ophthalmoscopy
    • OCT
  • Recommendations about when to refer and where to refer patients to, safely and appropriately
  • Record-keeping and patient communication

Last published: December 2022

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    Communication

    s.2 Communicate effectively with patients

    • Able to ask appropriate questions to elicit symptoms that may indicate serious neurological disease in patients presenting with suspect optic disc swelling.

    Clinical Practice

    s.5 Keep your knowledge and skills up to date

    • Understand the more common causes of unilateral/bilateral optic disc swelling and pseudopapillodema and so be able to recognise and differentiate signs of neurological significance and refer appropriately.

    s.7 Conduct appropriate assessments, examinations, treatments and referrals

    • Understand how to examine the optic discs effectively and interpret the results of specialist imaging tests such as OCT.

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      Please note: The markers in the video refer to chapter headings (listed below). You can use these markers to return to a specific section if you can’t watch the recording in one sitting. For more information on viewing Docet videos, including how to watch them in full screen and how to screencast, please go to our FAQs. 

      • Chapter headings

          1. Introduction and Case 1: 27-year-old woman 
          2. What is papilloedema?
          3. Causes of papilloedema and optic disc swelling
          4. How to recognise optic disc swelling
          5. Case 2: 17-year-old woman 
          6. What are the common causes of headache?
          7. Symptoms / signs of raised intracranial pressure 
          8. Causes of pseudopapilloedema 
          9. How can we distinguish papilloedema from pseudopapilloedema? 
          10. Imaging modalities to examine the optic disc
          11. Case 3: 49-year-old man 
          12. Case 4: 30-year-old lady 

          Q&A

          13. Question 1: Does the referral algorithm change if your patient is a child rather than an adult?
          14. Question 2: If you can see an optic cup dip – does this rule out papilloedema? 
          15. Question 3: Is it possible to get swelling or blurred margins just on the nasal side in early papilloedema?
          16. Question 4: Can you be asymptomatic in early stage papilloedema? 
          17. Question 5: Are there any relationships between COVID infection and papilloedema? 


          Please note that you can use the chapter headings or markers on the video to return to a specific section if you can’t watch the recording in one sitting.

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        • Programme references and information

        • Chang M, Binenbaum G, Heidary G, et al.  (2020) SL Imaging Methods for Differentiating Pediatric Papilledema from Pseudopapilledema: A Report by the American Academy of Ophthalmology. Ophthalmology; 127(10), pp 1416-1423

        • Chiang J, Wong E, Whatham A, et al. (2015) The usefulness of multimodal imaging for differentiating pseudopapilloedema and true swelling of the optic nerve head: a review and case series. Clinical & Experimental Optometry, 98(1); pp 12-24

        • Gise R, Gaier E, Heidary G (2019) Diagnosis and Imaging of Optic Nerve Head Drusen. Seminars in Ophthalmology; 34(4), pp 256-263

        • Malmqvist et al. (2018) The Optic Disc Drusen Consortium Recommendations for Diagnosis of Optic Disc Drusen Using Optical Coherence Tomography. J Neuro-ophthalmology.

        • Ozawa et al. (2019) The usefulness of symptoms alone or combined for general practitioners in considering the diagnosis of a brain tumour: a case control study using the clinical practice research database (CPRD) (2000-2014).  BMJ Open.

        • Rebelloda et al. (2017)  Optical Coherence Tomography to Differentiate Papilledema from Pseudopapilledema. Curr Neurol Neurosci Rep.

        • Sibony P, Kupersmith M (2016) "Paton's Folds" Revisited: Peripapillary Wrinkles, Folds, and Creases in Papilledema. [Review]; OCT Substudy Group of the NORDIC Idiopathic Intracranial Hypertension Treatment Trial. Ophthalmology, 123(6); pp 1397-9

        • Silverman A, Tatham A, Medeiros F, et al (2014) Assessment of optic nerve head drusen using enhanced depth imaging and swept source optical coherence tomography. Journal of Neuro-Ophthalmology, 34(2); pp 198-205


        • Docet would like to thank the following for her contribution to this programme:

          Dr Denize Atan, Consultant in Neuro-ophthalmology – University of Bristol & Bristol Eye Hospital

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