Fluorescein Angiographic Identification of Optic Disc Drusen With and Without Optic Disc Edema

Abstract

Background The fluorescein angiographic criteria for differentiating optic disc drusen (ODD) from optic disc edema have been unclear. We designed a study to identify distinguishing angiographic features of each and to apply them to cases where both drusen and edema were present. Methods A computer search was performed for cases evaluated in a university academic neuro-ophthalmology consultative practice and coded as ODD; all cases were reviewed, and those with fluorescein angiography were selected for further study. Cases were classified as either buried or surface ODD. Ten cases with papilledema were selected for comparison. Eight cases of coexistent drusen and edema were identified. Autofluorescence, early leakage, early blockage, early and late nodular staining, late peripapillary staining, and late leakage were tabulated. Results Two hundred sixteen cases of ODD were identified; 62 (116 eyes) had adequate fluorescein angiography for study. Twenty-three eyes were classified as surface ODD; 90% demonstrated early nodular staining of the disc, with late nodular staining in 90% and late circumferential peripapillary staining in 22%; autofluorescence was visible in 93% with preinjection photography. Eighty-three eyes were classified as buried ODD; 25% demonstrated early nodular staining, with late nodular staining in 29% and late circumferential peripapillary staining in 80%; autofluorescence was visible in 12% of those with preinjection photography. In 9 eyes, buried ODD were present with superimposed true edema. In these eyes, early dye leakage, late nodular hyperfluorescence, and late leakage were present. Conclusion Early and late fluorescein angiographic features reliably distinguish ODD from edema and may be particularly useful when the conditions coexist.

The role of orbital ultrasonography in distinguishing papilledema from pseudopapilledema

“…29 However, the fluorescein angiographic findings can be misinterpreted, especially when differentiating between dye leakage and staining. This is particularly true in persons who have pseudopapilledema without drusen (false-positive patients in our cohort).…”

“…These tests include magnetic resonance imaging (MRI) of the brain and orbits to look for structural intracranial lesions or signs of intracranial hypertension; 3 orbital ultrasonography to look for buried drusen or presence or absence of dilated retrobulbar optic nerve sheaths; 4 and lumbar puncture to measure intracranial pressure. 5 In addition, computed tomography (CT) scan of the orbits, 6 fluorescein angiography, 7 and optical coherence tomography (OCT) [8][9][10] have also been utilized in differentiating these two conditions. Among these modalities, orbital ultrasonography is a useful tool that is rapid, minimally invasive, cost-effective, and poses minimal risk to patient safety.…”

The cost-effectiveness of different strategies to evaluate optic disk drusen in children

“…Surface optic disk drusen usually exhibit autofluorescence and nodular staining with fluorescein angiography; however, it is less helpful for diagnosing buried drusen. Pineles and Arnold 13 classified 9 of 83 eyes with buried optic disk drusen as also having optic disk edema based on their fluorescein angiographic findings. However, after a further work-up, only 2 of these eyes were found to have true papilledema; the other 7 eyes had ischemic optic neuropathy, diabetic papillopathy, or no identifiable cause.…”

The Urgency of Neuroimaging Among UK Neuro-Ophthalmologists: Consensus and Disagreement

“…Papilloedema is universally recognised as a red-flag sign in headache, 15 but the presence of drusen is not necessarily reassuring as drusen can coexist with papilloedema. 16 Some, but not all of the respondents felt that the presence of drusen did not obviate the need for urgent neuroimaging, especially with reduced visual function. Consensus was reached for semi-urgent imaging in unilateral or bilateral optic atrophy in an older patient diagnosed incidentally by an optician, associated with mildly reduced visual function.…”