Referral patterns and pathways for intracranial hypertension
Reviewed by Lauren Hepworth

The authors present a retrospective case review of individuals with suspected raised intracranial pressure (ICP) over a 12-month period a single tertiary neuro-ophthalmology centre. Cases were categorised into four groups based on examination by neuro-ophthalmology; 1) referred after identification of secondary radiologic finding of intracranial hypertension following a brain scan for any reason, 2) referred with confirmed or suspected papilloedma, 3) referred with confirmed or suspected idiopathic intracranial hypertension (IIH) with or without papilloedema, 4) referred with a cerebral spinal fluid (CSF) leak and concern as a result of IIH. The following was extracted from the medical notes: demographics, neuro-ophthalmology examination details, ocular imaging, referral patterns, type of neuroimaging, final neuro-ophthalmic diagnosis, and final disposition. A total of 247 individuals were identified with suspected ICP from 1262 new referrals. Five percent of these were referred with coincidental radiologic findings of intracranial hypertension. A third of these were started on treatment following radiological findings. Active papilloedema was only identified in 27% of those referred with a diagnosis of IIH. The authors highlight the low predictive value of secondary radiologic finding of intracranial hypertension in identifying active IIH. They argue against the routine practice of a full work up for IIH with coincidental radiologic findings, potentially subjecting patients to unnecessary invasive procedures. The examples given were lumbar punctures (n=14) and treatment with acetazolamide / topiramate (n=10). The majority required no further intervention once the presence of papilloedema had been excluded. Fundoscopy was not attempted in ~50% prior to referral to ophthalmology. The authors do acknowledge the rare possibility of IIH without papilloedema and discuss how this should be approached. Limitations of this study are outlined including the retrospective methodology and inclusion from outpatient settings only, which may underestimate the number of referrals. Referrals enquiring about the presence of papilloedema could be assessed by optometry or general ophthalmology to reduce burden on neuro-ophthalmology services.

Presumptive idiopathic intracranial hypertension based on neuro imaging findings: a referral pattern study.
Aung AB, Chen BS, Wicks J, et al.
JOURNAL OF NEURO-OPHTHALMOLOGY
2023;43:55–62.