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BackgroundStenting of the intracranial venous sinuses is used as a treatment in certain cases of idiopathic intracranial hypertension (IIH). Interest in, and experience of, this technique is growing, particularly in recent years. We sought to provide an updated systematic review and meta-analysis of the use of venous stenting in these patients, examining clinical outcomes.MethodsA literature search of venous stenting in IIH patients was performed. Using random-effects meta-analysis, we evaluated the following outcomes: clinical resolution of papilledema; headaches and pulsatile tinnitus; recurrence of symptoms after stenting; and complications.ResultsTwenty articles from 18 different centers were included. In a total of 474 patients. 418 were female (88%). The mean age of the patients was 35, while the mean body mass index (BMI) was 35 kg/m2. Median follow-up was 18 months. The overall rate of improvement in papilloedema was 93.7% (95% CI 90.5% to 96.9%), while the overall rate of improvement or resolution of headache was 79.6% (95% CI 73.3% to 85.9%). Pulsatile tinnitus resolved in 90.3% (95% CI 83.8% to 96.70%), while the overall rate of recurrence of IIH symptoms after stenting was 9.8% (95% CI 6.7% to 13%). The rate of major complications was 1.9% (95% CI 0.07% to 3.1%).ConclusionsVenous sinus stenting in patients with IIH who are refractory to medical therapy appears to have an excellent safety profile and is associated with significant improvements in headaches, pulsatile tinnitus, and papilledema.

A condition in which the optic nerve inside the eye is swelled due to increased intracranial pressure is known as papilledema. The abnormalities due to papilledema such as opacification of Retinal Nerve Fiber Layer (RNFL), dilated optic disc capillaries, blurred disc margins, absence of venous pulsations, elevation of optic disc, obscuration of optic disc vessels, dilation of optic disc veins, optic disc splinter hemorrhages, cotton wool spots and hard exudates may result in complete vision loss. The ophthalmologists detect papilledema by means of an ophthalmoscope, Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and ultrasound. Rapid development of computer aided diagnostic systems has revolutionized the world. There is a need to develop such type of system that automatically detects the papilledema. In this paper, an automated system is presented that detects and grades the papilledema through analysis of fundus retinal images. The proposed system extracts 23 features from which six textural features are extracted from Gray-Level Co-occurrence Matrix (GLCM), eight features from optic disc margin obscuration, three color based features and seven vascular features are extracted. A feature vector consisting of these features is used for classification of normal and papilledema images using Support Vector Machine (SVM) with Radial Basis Function (RBF) kernel. The variations in retinal blood vessels, color properties, texture deviation of optic disc and its peripapillary region, and fluctuation of obscured disc margin are effectively identified and used by the proposed system for the detection and grading of papilledema. A dataset of 160 fundus retinal images is used which is taken from publicly available STARE database and local dataset collected from Armed Forces Institute of Ophthalmology (AFIO) Pakistan. The proposed system shows an average accuracy of 92.86% for classification of papilledema and normal images. It also shows an average accuracy of 97.85% for classification of already classified papilledema images into mild and severe papilledema. The proposed system is a novel step towards automated detection and grading of papilledema. The results showed that the technique is reliable and can be used as clinical decision support system.

Idiopathic intracranial hypertension (IIH) is a neuro-ophthalmological condition characterised by a raised intracranial pressure and papilloedema that causes disabling headaches. The main risk factors of female sex and living with obesity have been known for some time, however the knowledge of the underlying pathophysiology is evolving. Papilloedema can impact the visual function, and the majority of people are offered acetazolamide. Those with sight threatening disease need urgent management, though there is little high quality evidence to recommend any particular surgical intervention. Headache treatment is an unmet clinical need and simple medication overuse advice has the potential to reduce the chronification of migraine-like headaches. IIH is emerging as a systemic metabolic disease distinct from people living with obesity alone. While weight loss is the main stay of disease modifying therapy this is challenging to access and many healthcare professionals that manage the condition have no formal training or accessible pathways for weight management. The aim of this “how to do it” article is to present the latest advances in knowledge of IIH that we pragmatically included in routine clinical care for people living with the condition.

Previous reports suggest an association between the degree of optic nerve head edema and CSF pressure (CSFp) in idiopathic intracranial hypertension (IIH). We hypothesized that CSFp would be associated with Frisén papilledema grade (FPG) and other clinical features, and that FPG would modify the CSFp response to acetazolamide in participants in the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT). In the IIHTT, eligible patients underwent lumbar puncture (LP) prior to enrollment and were randomly assigned to one of two treatment groups: acetazolamide plus supervised diet or placebo plus supervised diet. Trial eligibility required baseline CSFp ≥250 mm H 2 O or ≥200 mm H 2 O with compelling clinical or imaging IIH findings. Associations between CSFp and FPG and other clinical features were examined at baseline. The effect of acetazolamide on 6-month change in CSFp was examined in those with low FPG (grades I–III) and those with high FPG (grades IV–V) at baseline. All 165 enrolled subjects had a baseline LP and 85 had an LP at 6 months. There was an association between CSFp and FPG at baseline: CSFp was more elevated in subjects with high FPG (378 ± 90 mm H 2 O, n  = 50) than in subjects with low FPG (331 ± 77, n  = 115, p  = 0.002). At 6 months, acetazolamide had a similar effect on CSFp in subjects with high FPG (−79.9 mm H 2 O) and in subjects with low FPG (−50.9 mm H 2 O, p  = 0.50). We found a modest association between CSFp and FPG. Acetazolamide had a beneficial effect on CSFp regardless of baseline FPG.

Purpose To determine the prevalence of papilledema among patients referred for suspected papilledema and identify symptoms associated with increased intracranial pressure. Methods This retrospective study included 514 patients referred to the ophthalmology clinic with suspected papilledema. Patient records were reviewed for demographic details, symptoms, and diagnostic outcomes. Examinations included best-corrected visual acuity (BCVA) assessments, fundoscopic evaluations, visual field (VF) tests, optical coherence tomography (OCT)-retinal nerve fiber layer (RNFL) thickness and fundus photographs. The rates of detected papilledema and pseudopapilledema, along with associated symptoms, were evaluated. Results Of 514 patients, papilledema was diagnosed in 109 cases (21.2%). Idiopathic intracranial hypertension was the most common etiology (n = 91), yet cases with serious underlying causes, such as intracranial tumors (n = 5) and cerebral venous sinus thrombosis (n = 5), were also identified. Headache was a frequent symptom but showed no significant correlation with papilledema ( p  = 0.653), while transient visual obscurations (TVOs) demonstrated a strong association ( p  < 0.001). Among papilledema patients, 33 had full BCVA, and 37 had a VF MD of − 2 dB or better. Abnormal VF (MD worse than − 2 dB) was found in 36.4% of patients with full BCVA. It was observed that the RNFL thickness in all quadrants was greater in the papilledema group compared to the healthy optic disc group. Pseudopapilledema, present in 20 patients (3.9%), was frequently due to optic disc drusen. There were no statistically significant differences in symptoms between patients with papilledema and those with pseudopapilledema. Conclusion Papilledema screening is a common consultation, particularly in the presence of accompanying symptoms, and accurate evaluation is crucial, especially for patients presenting with TVOs. Abnormal VFs were detected in patients with normal BCVA, most commonly presenting as an enlarged blind spot. This highlights that BCVA alone is insufficient for diagnosing and monitoring suspected papilledema. Recognizing papilledema is vital given its association with conditions carrying significant morbidity and mortality risks, such as intracranial tumors and thrombosis. Enhanced ophthalmoscopy skills among referring physicians may streamline the referral process, reduce unnecessary consultations, and improve patient outcomes by enabling timely intervention for high-risk cases.

Papilledema describes optic nerve head (ONH) swelling due to raised intracranial pressure which can lead to complications including visual loss. Differentiating it from pseudopapilledema is often challenging and may require invasive investigations. Optical Coherence Tomography (OCT) is a non-invasive imaging modality, allowing visualisation of the ONH. We identified OCT-derived biomarkers for papilledema and pseudopapilledema in the existing literature. 213 patients with confirmed papilledema, optic disc drusen (ODD), tilted optic discs (TOD) or crowded optic discs (COD) were included. OCT scans were analysed for qualitative and quantitative biomarkers, with sensitivity, specificity, and AUC calculated for individual and combined biomarkers. Logistic regression modelling including qualitative biomarkers to differentiate papilledema from ODD and COD demonstrated a sensitivity and specificity of 89% and AUC of 0.96. Inclusion of TOD reduced the sensitivity of the model to 66%. In a model differentiating papilledema from TOD, the best-performing biomarker achieved a sensitivity of 87%, specificity of 61% and AUC of 0.83. Using qualitative biomarkers, we identified a model with high sensitivity and specificity to differentiate papilledema from ODD and COD. Quantitative biomarkers displayed high AUCs for differentiating TOD from papilledema. Our findings show that OCT demonstrates promising utility in differentiating papilledema from pseudopapilledema.

Spaceflight associated neuro-ocular syndrome (SANS) refers to a distinct constellation of ocular, neurological and neuroimaging findings observed in astronauts during and following long duration spaceflight. These ocular findings, to include optic disc oedema, posterior globe flattening, chorioretinal folds and hyperopic shifts, were first described by NASA in 2011. SANS is a potential risk to astronaut health and will likely require mitigation prior to planetary travel with prolonged exposures to microgravity. While the exact pathogenesis of SANS is not completely understood, several hypotheses have been proposed to explain this neuro-ocular phenomenon. In this paper, we briefly discuss the current hypotheses and contributing factors underlying SANS pathophysiology as well as analogues used to study SANS on Earth. We also review emerging potential countermeasures for SANS including lower body negative pressure, nutritional supplementation and translaminar pressure gradient modulation. Ongoing investigation within these fields will likely be instrumental in preparing and protecting astronaut vision for future spaceflight missions including deep space exploration.

Background Idiopathic intracranial hypertension (IIH) is increasingly prevalent, yet longitudinal outcome data are scarce. This study aimed to characterise demographic and longitudinal clinical changes in a cohort of patients with IIH. Methods Retrospective cohort analysis on adult patients diagnosed with IIH (Friedman criteria) enrolled in the neuro-ophthalmology database (NODE) across two tertiary centres. Baseline demographic data was obtained at first assessment, with clinical and paraclinical outcomes collected longitudinally. Multivariable statistical analysis identified factors associated with poorer visual outcomes. Results A total of 221 patients were included. 91.8% were female (ratio 11:1). Mean age at presentation was 29.2 ± 8.1 years with mean body mass index (kg/m 2 ) at diagnosis of 38.7 ± 9.4. Headache was the most common symptom. Papilloedema was found in 95.5% of patients at baseline. Mean CSF opening pressure was 32.67 ± 6.85cmCSF (range 25–76). Visual outcomes remained stable over time. Trajectory plots showed no deviations in visual acuity, while regression models found no associations with sex, site or age. A higher retinal nerve fibre layer thickness and greater baseline Frisen grade were associated with worse outcomes. Baseline papilloedema grade and CSF opening pressure emerged as early prognostic indicators, aiding risk stratification for those with a greater probability of persistent optic nerve abnormalities including higher retinal nerve fibre layer elevation and sustained atrophic changes over time. Conclusions This study offers insights into visual outcomes in IIH, emphasising the importance of early recognition, risk stratification, and intervention in those with a more severe clinical phenotype at presentation.

Background/Objectives Our aim was to compare factors associated with poor versus good visual outcomes in idiopathic intracranial hypertension (IIH) patients with severe papilledema at initial presentation. Subjects/Methods Retrospective review of consecutive IIH patients (1/1/2013-6/10/2023) with severe papilledema (Frisén grade 4–5 and/or atrophy in at least one eye); Patients were divided into “poor visual outcome” (poor visual acuity and constricted visual field in at least one eye) and “good visual outcome” (good visual acuity and only mild visual field changes in both eyes) at >6 months for medically-treated patients and >3 months follow-up for surgically-treated patients. Results We included 134 IIH patients with severe papilledema (70 had poor and 64 had good visual outcomes). No significant differences existed for age, gender, race, hypertension, haemoglobin, or cerebrospinal fluid opening pressure. The poor-outcome group had significantly greater BMI (mean 39.2 vs 35.1 kg/m 2 , p = 0.004), and worse initial HVF-MD (–20.04 vs –5.81 dB, p < 0.0001). Poor-outcome patients saw more prior health-care providers (4.7 vs 2.4, p < 0.0001), with delayed neuro-ophthalmology encounters (58.5 vs 15.2 weeks, p = 0.001). 41.4% of poor-outcome patients were initially seen in outside emergency departments (ED) (vs 14.1% of good-outcome patients, p = 0.0005), while only 27.1% were seen by eye-care providers (vs 53.1% of good-outcome patients, p = 0.0027). No poor-outcome patients initially consulted our institution’s ED vs 7.8% of good-outcome patients. Conclusions Although patients with poor visual outcome did not seek medical care later than good outcome patients, they had delayed diagnosis/treatment because of prior outside ED visits and lack of prior eye-care provider evaluations, suggesting that early diagnosis and specialized management of papilledema is essential for patients with symptoms of intracranial hypertension.

Background/AimsPrior studies support an association between increased retinal venule diameter and elevated intracranial pressure (ICP). The purpose of this study was to test the hypothesis that retinal venule diameters decrease in association with long-term therapy for high ICP in subjects with idiopathic intracranial hypertension (IIH).MethodsThis is a retrospective analysis of multicentre randomised controlled trial data. Standardised procedures were used to measure area of optic nerve head elevation (ONHA) and diameters of 4 arterioles and 4 venules 2.7 mm from the optic disc centre on fundus photos collected at baseline and after 6 months of randomised treatment with placebo+diet or acetazolamide+diet in subjects participating in the IIH Treatment Trial (IIHTT) (n=115). Change in arteriole (Da) and venule (Dv) diameters from baseline to 6 months was studied as a function of IIH, haemodynamic and demographic variables.ResultsDv decreased following 6 months of therapy (8.1 µm, 5.9%, p<0.0005) but Da did not change. Dv change was associated with ONHA change (p<0.0005, r=0.47) and this association persisted in multiple variable models.ConclusionsRetinal venule diameter decreased, and arteriole diameter did not change in association with treatment for elevated ICP with a weight loss intervention and placebo or acetazolamide in IIHTT participants. Further study is needed to determine how retinal vessel measurements can be combined with other clinical observations to inform disease management.