The Dubious Obscuration

A3-year-old girl presented with a history of squinting of either eye, the past 4 months. On examination, her vision using Lea symbols was 6/9.5 in the right eye and 6/15 in the left eye with a cycloplegic refraction of +6.00DS − 2.00DC × 180 in both eyes. She had an intermittent divergent squint of 35PD for distance and near. Pupils were reactive to light. Her anterior segment examination was unremarkable. Fundus findings are shown in Figure 1.

Figure 1.

(a and b) Color fundus photograph of optic nerve head in the right and left eye, respectively. (c) B.scan image of either eye

Questions

1. What is the next step to confirm the diagnosis?

   1. MRI Brain

   2. CSF tap with opening pressure

   3. Disc photograph with autofluorescence

   4. Autoimmune workup

2. What is your diagnosis?

   1. Papilledema

   2. Optic disc drusen

   3. Bilateral optic neuritis

   4. Optic disc pit

3. What is your plan of management in these cases?

   1. Oral steroids

   2. Neurologist opinion for intracranial lesion

   3. Immunomodulators

   4. Patching

Answers

1. C)

2. B)

3. D)

Discussion

The child’s B-scan ultrasonography showed a hyperreflective echo over the optic nerve head persisting even in low gain. Autofluorescence imaging was done which showed mild hyperautofluorescence at the disc. This was suggestive of pseudopapilledema secondary to optic disc drusen. Hence, she was advised glasses and patching for bilateral amblyopia due to uncorrected hypermetropia and asked to review in 4 months for vision assessment.

Optic disc drusen are proteinaceous deposits over the optic nerve head which can get calcified with age. They occur due to axoplasmic stasis and can result in ganglion cell loss with age.[1] The children are usually asymptomatic and drusen are picked up incidentally on routine examinations. Superficial drusen give a “lumpy-bumpy” appearance, but deep buried drusen are not visible on fundoscopy and appear as blurred disc margins, making it essential for us to differentiate it from papilledema.

Clinically, pseudopapilledema will have clearly visible vessels over the disc in the absence of disc hyperemia, splinter hemorrhages, or Patons lines. Investigations such as B scan and autofluorescence can prevent unnecessary expenditure on expensive neuroimaging.[2]

Rare complications in eyes with drusen include visual field defects, anterior ischemic optic neuropathy, or choroidal neovascular membrane.[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.