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EW FEATURE 38 Neuro-ophthalmology for the anterior segment surgeon • June 2018 AT A GLANCE • Fluorescein angiography had the highest accuracy—97%—for classifying an eye as PE or PPE. • The use of isolated imaging mo- dalities was more likely to lead to misinterpretation of PE as PPE. • Optic disc drusen is the most common reason optic nerves are misinterpreted as swollen. by Rich Daly EyeWorld Contributing Writer Getting nerve imaging right PPE owing to superficial ODD. The subjects underwent imaging with B-scan ultrasonography, fundus photography, autofluorescence, fluo- rescein angiography (FA), optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL), and volumetric OCT scans through the optic nerve head with standard spectral domain (SD OCT) and enhanced depth imaging (EDI OCT) settings. Images were read by the masked neuro-ophthalmologists, and the final image interpretation was based on two of three reads. When the im- age interpretations were compared with clinical diagnosis to calculate accuracy and misinterpretation rates of each imaging modality, fluoresce- in angiography was found to have the highest accuracy—97%—for classifying an eye as PE or PPE. The ability of other imaging modalities to accurately distinguish between PE and PPE ranged from 62% with autofluorescence to 74% with ultrasonography. Accuracy of imaging modalities to identify suspected buried optic disc drusen ranged from 53% for fundus photography to 95% for fluorescein angiography. The authors found that FA of eyes with PE showed leakage of the optic nerve, while eyes with sus- pected buried ODD demonstrated New research shows varying degrees of accuracy among imaging options that aim to identify optic nerve swelling E ven the best imaging tech- nologies can struggle to accurately diagnose some retinal and optic nerve problems. That was the finding of research published in the journal Ophthalmol- ogy that examined the accuracy of imaging reviewed by three masked neuro-ophthalmologists. 1 The prospective observational study imaged 19 children diagnosed with papilledema (PE), pseudopap- illedema (PPE) owing to suspected buried optic disc drusen (ODD), and Fluorescein angiography characteristics of superficial optic disc drusen (top) and optic disc edema (bottom). Superficial optic disc drusen demonstrated staining, with nodular hyperfluorescence that did not increase in area over time. In contrast, optic disc edema was seen as fluorescein leakage, with increased area of hyperfluorescence over time. no hyperfluorescence, and eyes with superficial ODD showed nodular staining. They concluded that FA was the best imaging technique for correctly classifying pediatric eyes as PPE or PE. No cases of PE were misinterpret- ed on FA. Additionally, FA images were interpreted most consistently by the image readers. Among the other imaging options, fundus photography had Monthly Pulse Neuro-ophthalmology for the anterior segment surgeon EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthal- mologist. Each month we send an online survey covering different topics so readers can see how they compare to our survey. If you would like to join the physicians who take a minute a month to share their views, please send us an email and we will add your name. Email anne@eyeworld. org and put "EW Pulse" in the subject line. In a patient who had nonarteritic anterior ischemic optic neuropathy (NAION) after their first cataract surgery, I would: Delay surgery on the second eye as long as possible Perform cataract surgery on the second eye using my normal criteria Delay cataract surgery moderately Refer the patient to another cataract surgeon Following varicella zoster with ocular involvement: I start the patient on a 10-day course of anti-viral therapy I start the patient on long-term anti-viral therapy I refer the patient

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