Diagnosis and Grading of Papilledema in Patients With

Home , Papilledema

CLINICAL SCIENCES Diagnosis and Grading of Papilledema in Patients With Raised Intracranial Pressure Using Optical Coherence Tomography vs Clinical Expert Assessment Using a Clinical Staging Scale

Colin J. Scott, MD; Randy H. Kardon, MD, PhD; Andrew G. Lee, MD; Lars Frise´n, MD, PhD; Michael Wall, MD

Objectives: To compare and contrast 2 methods of quan- tographs correlated well (R=0.85). OCT total retinal thick- titating papilledema, namely, optical coherence tomog- ness and MFS grade from photographs had a similar cor- raphy (OCT) and Modified Frise´n Scale (MFS). relation of 0.87. Comparing OCT RNFL thickness with OCT total retinal thickness, a slope of 1.64 suggests a Methods: Digital optic disc photographs and OCT fast greater degree of papilledema thickness change when retinal nerve fiber layer (RNFL) thickness, fast RNFL map, using the latter. total retinal thickness, and fast disc images were obtained in 36 patients with papilledema. Digital optic disc Conclusions: For lower-grade abnormalities, OCT com- photographs were randomized and graded by 4 masked pares favorably with clinical staging of optic nerve pho- expert reviewers using the MFS. We performed Spear- tographs. With higher grades, OCT RNFL thickness pro- man rank correlations of OCT RNFL thickness, OCT total cessing algorithms often fail, with OCT total retinal retinal thickness, and MFS grade from photographs. thickness performing more favorably.

Results: OCT RNFL thickness and MFS grade from pho- Arch Ophthalmol. 2010;128(6):705-711

APILLEDEMA, OR OPTIC DISC patient fixation stability during imaging swelling due to raised intra- without eye tracking and the failure of seg- cranial pressure, has been mentation algorithms for defining RNFL graded using the Frise´n thickness and total retinal thickness in eyes Scale.1 This scale uses visual with severe papilledema. featuresP of the optic disc and peripapil- Although fundus photographs require lary retina to stage optic disc edema. Its subjective interpretation, they show de- reproducibility has been validated,1 but it tailed topographic relationships of optic is limited by use of an ordinal scale. disc edema that may be difficult to quan- Optical coherence tomography (OCT) tify and document on clinical examina- is a potential tool to quantify changes in the tion. Unlike OCT, photographic artifacts Author Affiliations: degree of papilledema and to monitor the (eg, defocus or incorrect light exposure) Department of Ophthalmology efficacy of treatment interventions. First de- that could interfere with interpretation are and Visual Sciences, Carver scribed in 1991 by Huang et al,2 OCT is a usually obvious. School of Medicine, University cross-sectional imaging technique that OCT is useful in evaluating various oph- of Iowa, and Veterans Affairs Hospital, Iowa City (Drs Scott, quantitatively assesses multiple layers of the thalmic disorders such as band atrophy, Kardon, Lee, and Wall); and retina, allowing measurement of the reti- glaucoma, diabetic retinopathy, cystoid Institute of Neuroscience and nal nerve fiber layer (RNFL) with a reso- macular edema, central serous retinopa- Physiology, Department of lution of approximately 10 µm using time- thy, macular hole formation, optic nerve Clinical Neurosciences, domain variables.3-5 Direct measurements head pits, and ischemic optic neuropa- Sahlgrenska Academy, are calculated by a computer algorithm to thy.12-18 Most of these conditions involve University of Gothenburg, quantify the nerve fiber layer and total reti- RNFL thinning. Few studies evaluated the Gothenburg, Sweden nal thickness. OCT offers several advan- use of OCT in measuring RNFL or total reti- (Dr Frise´n). Dr Lee is now with tages over conventional photographic nal thickening due to papilledema. A 2007 the Department of imaging such as use with small pupil sizes study19 compared the findings of OCT vs Ophthalmology, The Methodist Hospital and the Departments and nuclear cataracts. OCT findings are rea- disc photographs in children with idio- of Ophthalmology, Neurology, sonably reproducible on successive mea- pathic intracranial hypertension. Another 20 and Neurosurgery, Weill Cornell surements in normal eyes and in eyes with study assessed the importance of RNFL Medical College New York, glaucoma.6-11 Despite these advantages, limi- thickness analysis in intracranial hyperten- New York. tations of OCT include the requirement for sion using imaging laser polarimetry. In pa-

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/04/2021 dopapilledema but did not directly compare OCT vs fundus photograph grades. To our knowledge, this is the first study to compare OCT RNFL thickness and OCT total retinal thickness with fundus disc photographs in adults having raised intracranial pressure. Our objectives were to compare and contrast OCT and Modified Frise´n Scale (MFS) grading with the peripapillary RNFL in quantifying optic disc edema.

METHODS

Digital optic disc photographs of the right or left eye were selected for review if corresponding OCT images of the RNFL were Grade 0 Grade 1 available and if photographs and OCT images were of sufficient quality. For OCT analysis, the circular image had to be cen- tered on the nerve, the signal strength had to be at least 5 (range, 1[lowest]-10 [highest]), and the proprietary algorithm used by the manufacturer (OCT3; Zeiss Meditech, Dublin, California) had to successfully delineate the borders of the RNFL on manual inspection of the images. The proprietary algorithm creates a best- fit estimate of the inner and outer borders of the RNFL and the total retinal thickness to calculate the mean thickness, as demonstrated by the overlayed white lines of the B-scan in Figure 1. Algorithm failure occurred when the borders of the retinal layers delineated by the software were qualitatively incompatible with the borders inferred by experts (C.J.S. and R.H.K.). For fundus photographs, the optic nerve had to be in focus to allow evaluation of the RNFL at the disc border. Analysis was monocular rather than binocular because of some poor photographic quality or failure to capture the entire extent of the z-axis by OCT Grade 2 Grade 3 due to peripapillary elevation and cropping of the B-scan in 1 of 2 eyes. Furthermore, use of both eyes would violate a principle of parametric statistics, as the results of one eye are not independent of the other eye. Although the relationship between eyes could be accounted for with nested analysis of variance, using both eyes in some patients would have complicated our statis- tical analysis. Patients retrospectively identified as having raised intracranial pressure at some point in their clinical course from January 2004 to March 2008 were included in the study, and the imaging studies chosen were from the patient’s first presenta- tion to our clinic for evaluation. While most cases were idiopathic, the specific etiology was not addressed, as the pathogenesis of disc edema pathogenesis of papilledema was secondary to raised intercranial pressure in all cases is static and should not affect comparison of disc appearance with OCT values. No other cause of visual loss or optic disc edema was present such as optic nerve compression, inflammatory optic neuropathy, or is- Grade 4 Grade 5 chemic optic neuropathy. Monocular digital photographs were randomized and graded by 4 masked expert reviewer neuro- Figure 1. Representative fundus photographs of each Modified Friseń Scale ophthalmologists (3 from the University of Iowa and 1 from the grade as summarized in Table 1. A representative optical coherence University of Gothenburg, Sweden). Photographs were viewed tomography image is below each disc grade. Overlayed white lines of the ϫ optical coherence tomography image represent borders of the retinal nerve at 1600 1200 resolution (SyncMaster 213T; Samsung, Ridge- fiber layer thickness (upper and middle lines) and the total retinal thickness field Park, New Jersey). (upper and lower lines) estimated using the algorithm (OCT3; Zeiss We used an adaptation of a clinical staging scale initially de- Meditech, Dublin, California). Modified Friseń Scale key features (Table 1) are scribed by one of us (L.F.) (Table 1 and Figure 1).1 The first 2 well demonstrated. grades are primarily dependent on changes surrounding the optic disc such as decreased translucency and opacification of the tients with retinal vein occlusions and inflammatory op- peripapillary nerve fiber layer (the term blurring is avoided be- tic neuropathies, Menke et al21 found that OCT RNFL cause it has many meanings, including lack of image focus). Grade thickness was increased compared with that in control sub- 0 represents no optic disc edema, and grades 1 through 5 rep- 22 resent increasing severity of optic disc edema. We modified the jects. Hoye et al used OCT to demonstrate subretinal Friseń Scale by identifying a key feature for each grade, with the macular edema in papilledema, and OCT has been used other criteria considered minor. For grade 1, the key feature is to measure RNFL thickness in patients with optic neuri- the presence of a C-shaped halo of opacification of the RNFL at tis.23,24 Other studies25-27 compared OCT (as well as auto- the region of the optic disc border; a gap remained at the loca- mated perimetry) RNFL thickness in papilledema and pseu- tion of the maculopapular bundle. Rarely, a thin smooth-edged,

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/04/2021 ring-shaped peripapillary light reflex may be present in normal anatomy; when present, it is a continuous reflex. Therefore, patho- Table 1. Modified Frise´n Scale logic designation requires irregularity and breakup of any ring- shaped peripapillary reflex (grade 1 in Figure 1). Grade 2 is char- Papilledema Grade acterized by a circumferential halo with decreased translucency 0 (Normal Optic Disc) (opacification of the RNFL), with complete visualization of each Prominence of the retinal nerve fiber layer at the nasal, superior, and major retinal artery and vein along its length as it courses over inferior poles in inverse proportion to disc diameter the optic disc and its border. Grade 3 has loss of visualization Radial nerve fiber layer striations, without tortuosity (discontinuity) along a segment of at least 1 major vessel as it 1 (Minimal Degree of Edema) courses over the optic disc margin but continues in the center C-shaped halo that is subtle and grayish with a temporal gap; obscures of the optic nerve. Grade 4 is characterized primarily by discon- underlying retinal detailsa tinuity due to opacification of at least 1 but not all major vessels Disruption of normal radial nerve fiber layer arrangement striations on the optic disc. Temporal disc margin normal In the original description by Frise´n, grade 5 is classified as 2 (Low Degree of Edema) follows: “Anterior expansion of the nerve head now dominates a over sideways expansion. The nerve head assumes a relatively Circumferential halo Elevation (nasal border) smooth, dome-shaped protrusion, with a narrow and smoothly No major vessel obscuration demarcated halo. The major retinal vessels climb steeply over the dome surface. Segments of these vessels may or may not be 3 (Moderate Degree of Edema) totally obscured by overlying swollen tissue.”1(p16) Because this Obscuration of Ն1 segment of major blood vessels leaving disca grade did not have a clear-cut primary feature, we added one in Circumferential halo which grade 5 is reached when there is obscuration of all major Elevation (all borders) vessels on the optic disc. We excluded grade 5 cases from our Halo (irregular outer fringe with finger-like extensions) analysis because the few examples did not have OCT images in 4 (Marked Degree of Edema) which the algorithm did not fail. Total obscuration on the disc of a segment of a major blood vessel on Corresponding OCT images of each grade are shown in the disca Figure 1. Compared with OCT RNFL thickness, OCT total reti- Elevation (whole nerve head, including the cup) nal thickness borders may demonstrate a greater degree of neu- Border obscuration (complete) rosensory detachment with increasing edema, but the soft- Halo (complete) ware algorithm can fail at severe papilledema levels, with borders Grade 5 (Severe Degree of Edema) appearing beyond the range of visualization by reviewers. For Obscuration of all vessels on the disc and leaving the disca MFS grading of the optic disc photographs, if there was uncertainty in assigning a grade between 2 increments, the lesser a Key features (major findings) for each grade. grade was given an additional “ϩ” symbol. For example, if it was difficult to determine whether there was a C-shaped halo or a 360° circumferential halo, the disc would be graded as 1ϩ. rate cohort of 101 patients was randomly selected from a database Because the first sign of papilledema in an experimental mon- of 224 patients with known papilledema at initial presenta- key model was optic disc elevation,28 grade 0ϩ was used to char- tion from the University of Iowa using the same Stratus OCT3 acterize elevation that exceeded grade 0 but lacked the char- to determine if borders were captured accurately. The image acteristics of grade 1. passed if the OCT algorithm followed the expected borders of OCT fast RNFL, fast RNFL map, and fast optic disc images RNFL thickness and total retinal thickness on the B-scan as were obtained at the time of digital color photography (Stra- evaluated by one of us (C.J.S.). The image failed if the algo- tus OCT3, Zeiss Meditech). The mean RNFL thickness and total rithm did not follow the expected borders. The respective disc retinal thickness were obtained if the proprietary algorithm photograph for each OCT image was evaluated and excluded seemed to follow the expected borders in their entirety on the if of insufficient quality. Digital photographs were reviewed and displayed B-scan and if the circular image seemed to be cen- graded by one of us (C.J.S.) using the MFS as previously de- tered on the video display. Most RNFL circular image data rep- scribed. The failure rate was calculated for each photographic resented 3 trials of each eye, for which the data were averaged. MFS grade similarly as for each OCT image. The trial with the most accurately appearing fit for RNFL borders along with the highest signal strength was chosen for fur- RESULTS ther analysis. OCT data with low signal strength (Ͻ5) or for which no trials had adequate RNFL border tracing over 360° of the circular image were excluded and tabulated. Among 36 patients with papilledema, 7 (19%) had grade Disc grade for each patient was based on majority rule among 0, 7 (19%) had grade 1, 10 (28%) had grade 2, 4 had grade 3 of us (R.H.K., A.G.L., and M.W.) using the same computer 3 (11%), and 8 (22%) had grade 4 disc edema using ma- monitor for evaluation. If all 3 reviewers were not in agreement, jority rule. The 3 reviewers agreed on grade most of the grading by 2 reviewers was used, with the third reviewer’s grade time, and only once was there more than a 1-grade differ- excluded. To evaluate possible higher correlation, 2 of us (R.H.K. ence by 1 reviewer compared with the other 2 reviewers and M.W.) arranged the photographs in ranked order from low- (Figure 2A). One-grade differences occurred between all est to highest amount of disc edema. As a cross-check, grading grades, and differences exceeding 1 grade occurred be- was performed by one of us (L.F.) and correlated with OCT find- tween grades 2 and 4 (Figure 2B). If the “ϩ” notation was ings independent of the 3 reviewers. We performed Spearman added to a grade, it was omitted to establish a numeric rank correlations of OCT RNFL thickness, OCT total retinal thickness, and MFS grade from photographs. scheme for further quantitative analysis. OCT RNFL thick- Because the Stratus OCT3 was not specifically designed to ness and total retinal thickness showed significant corre- measure papilledema, the software failure rate of the algo- lation with the MFS grade from photographs. rithm for determining RFNL thickness and total retinal thick- In grading papilledema, we found strong correlation ness was assessed as a function of papilledema grade. A sepa- between the MFS and OCT findings. When OCT RNFL

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/04/2021 A B Difference of 6 >1 grade 2.8 Expert 1 Expert 2 5 Expert 3 Expert 4 Majority rule 4 (experts 1-3)

3 Difference of 1 grade 41.7% Equal grading 2 55.5% Modified Frisén Scale Grade

0 0 5 10 15 20 25 30 35 40 Ranked Order of Modified Frisén Scale Grade

Figure 2. Papilledema grading differences in 36 patients. A, Among 3 reviewers using the Modified Friseń Scale. B, Between 2 reviewers using the Modified Friseń Scale and 1 reviewer using ranked order of Modified Friseń Scale grade. The y-axis is slightly offset to delineate each expert’s grade. Note the good concordance among reviewers.

A B 450 800

400 700 350 600 300 500 250 400 200 300 150 200

OCT RNFL Thickness, µM 100

R = 0.85 Retinal Thickness, µM OCT Total R = 0.87 50 100 P<.001 P<.001 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Modified Frisén Scale Grade Modified Frisén Scale Grade

Figure 3. Papilledema grading differences in 36 patients among reviewers. A, Using optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) thickness vs using Modified Frise´n Scale grade. B, Using OCT total retinal thickness vs using Modified Frise´n Scale grade.

thickness was compared with MFS grade from photo- RNFL thickness. When comparing OCT RNFL thickness graphs (using majority rule), Spearman rank correlation with OCT total retinal thickness, a strong linear relation- was 0.85 (PϽ.001). When OCT total retinal thickness ship was observed at R2=0.90 (y=1.64xϩ105.5) (PϽ.001) was compared with MFS grade from photographs, Spear- (Figure 5). The slope of 1.64 suggests a greater degree of man rank correlation was 0.87 (PϽ.001) (Figure 3). papilledema thickness change when using OCT total reti- In cross-check grading by one of us (L.F.), Spearman rank nal thickness. Among 199 eyes in 101 patients evaluated correlations were 0.79 (PϽ.001) and 0.83 (PϽ.001) for to analyze whether the algorithm was able to capture ex- the latter. pected borders of the RNFL and total retinal thickness, the Two of us (R.H.K. and M.W.) also ranked photo- highest failure rates were seen with higher grades of disc graphs based on lowest to highest amount of disc edema. edema (Figure 6). Higher failure rates were found with This was done to increase stratification of the data to dem- OCT RNFL thickness than with OCT total retinal thick- onstrate potential higher correlation when using a finer scale. ness. All photographs were of sufficient quality to assign Spearman rank correlation increased to 0.88 (PϽ.001) an MSF grade without failure, as most patients had sev- when OCT RNFL thickness was compared with ranked or- eral photographs taken at the same time and the highest- der of MFS grade (range, 1-36) (Figure 4). Spearman rank quality photograph was used for assessment. correlation increased to 0.90 (PϽ.001) when OCT total retinal thickness was compared with ranked order of MFS grade. Interobserver Spearman rank correlation between COMMENT the 2 reviewers was highly significant at 0.87. In majority rule when comparing MFS grading from photographs, OCT We found strong Spearman rank correlation between OCT total retinal thickness had higher correlation than OCT RNFL thickness, OCT total retinal thickness, and MFS

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400 700 350 600 300 500 250 400 200 300 150

RNFL Thickness, µM 200 100 Total Retinal Thickness, µM Total R = 0.88 R = 0.90 50 100 P<.001 P<.001 0 0 0 5 10 15 20 25 30 35 40 0 5 10 15 20 25 30 35 40 Ranked Order of Modified Frisén Scale Grade Ranked Order of Modified Frisén Scale Grade

Figure 4. Papilledema grading differences in 36 patients. A, Using optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) thickness vs using ranked order of Modified Frise´n Scale grade. B, Using OCT total retinal thickness vs using ranked order of Modified Frise´n Scale grade.

grade from photographs. The effect of papilledema can be seen on RNFL thickness and on RNFL total retinal 800 thickness. A disproportional increase of total retinal thick- 700 ness above that of the RNFL represents fluid from neu- 600 rosensory retinal detachment in the peripapillary retina. Therefore, OCT total retinal thickness may show pro- 500 portionally more change per degree of disc edema than 400

OCT RNFL thickness, which is a new finding. 300 OCT of total retinal thickness has not been well stud- 21 200 y = 1.64x + 105.5 ied in optic disc conditions; however, Menke et al found R2 = 0.90 that total retinal thickness was increased out of propor- Retinal Thickness, µM OCT Total 100 P<.001 tion to RNFL thickness in retinal vein occlusions compared with a control group having inflammatory optic neu- 0 50 100 150 200 250 300 350 400 450 ropathies. It was concluded that differences in the intrinsic OCT RNFL Thickness, µM pathogenesis of optic disc edema may differentially affect Figure 5. Note the excellent measurement correlation between optical the thickness of the RNFL compared with other layers of coherence tomography (OCT) total retinal thickness and OCT retinal nerve the retina. However, their study did not directly compare fiber layer (RNFL) thickness in 36 patients. RNFL thickness with total retinal thickness in optic disc edema and in differing severities of edema. affect fundus photographs.29-31 With digital photogra- The correlation between OCT and fundus appear- phy, variability may occur for several reasons, including ance of the disc was greatest when photographs were characteristics and calibration of the viewing monitor. ranked in continuous order of edema severity. Varia- Variability among examiners could also occur because tion in OCT measurements at each grade could be partly of direct examination vs photographic evaluation and due explained by the ordinal character of the MFS, as rank- to magnification and computer monitor variables. OCT ing the photographs in order within each grade resulted also has limitations (Table 2). For example, the quality in higher correlation between OCT findings and MFS of each image is eye (ie, media opacity) dependent and grade. We modified the Frise´n Scale in an attempt to im- operator dependent and can be affected by improper disc prove its reproducibility. We avoid the term blur,asthe centering and poor fixation. Low signal strength can also cause could be multifactorial, including media opacifi- significantly reduce data quality, which was often seen cation or other optical anomalies. Instead, we prefer the in higher grades of disc edema; however, data with sig- term obscuration to more clearly delineate the patho- nal strength of less than 5 were excluded in our study. logic effect at the peripapillary nerve fiber layer. We no Our study also demonstrated increased variability in longer include retinochoroidal folds as criteria for grade the mean OCT RNFL thickness and OCT total retinal 2 because they can occur at any disc stage. The scale has thickness with higher grades of disc edema. One of the been modified to no longer include domed disc in grade greatest limitations of the OCT3 is the proprietary algo- 5, as this has been difficult to define. Instead, grade 5 cri- rithm to trace the RNFL thickness and the total retinal teria include complete obscuration of all vessels on the thickness, which often cannot accurately outline thick- disc and leaving the disc. While the MFS is useful for daily nesses in advanced stages of papilledema. Although our practice and for clinical trials, limitations remain study found this to be less problematic when measuring (Table 2). Ophthalmoscopic evaluation and grading of total retinal thickness, the failure rate remained high for papilledema can show significant variability among ob- grade 5 papilledema at 33%. Disc hemorrhages can also servers and can be influenced by media opacities, cata- affect accuracy, as they may influence reflectivity in an ract formation, and pigment epithelium, which can also inconsistent manner. Even with evolving technology to

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60 60

50 50

40 40

No. of Eyes 30 No. of Eyes 30

20 20

10 10

0 0 0 1 2 3 4 0 1 2 3 4 Modified Frisén Scale Grade Modified Frisén Scale Grade

Figure 6. Pass rates and fail rates using optical coherence tomography (OCT) measurements vs Modified Frise´n Scale grade. A total of 199 eyes were evaluated in 101 patients. A, Using retinal nerve fiber layer (RNFL) thickness. B, Using total retinal thickness.

of papilledema. The algorithm defining total retinal thick- Table 2. Advantages and Disadvantages of Optical ness had a lower failure rate than that defining RNFL Coherence Tomography and Modified Frise´n Scale Grade thickness, indicating that OCT total retinal thickness mea- From Photographs for Quantifying Papilledema surement may be more robust, especially at higher grades of papilledema. The stronger correlation of MFS grade Modified Frise´n Scale Grade Optical Coherence Tomography From Photographs with total retinal thickness compared with RNFL thickness suggests that more emphasis should be placed on Advantage Advantage Reliable at lower grades More reliable at higher grades total retinal measurements. Continuous as opposed to ordinal Obvious artifacts can be ignored Optical coherence tomography can be a useful tool in measurement scale when observing key features the evaluation of papilledema by confirming or comple- Not as limited by pupil size Use among many specialties menting an examiner’s clinical examination. The advan- or cataracts without specialized tages are listed in Table 2 compared with digital optic equipment Requires less observer experience disc photographs; particularly, OCT quantification uses a continuous scale, whereas MFS grading from photo- Disadvantage Disadvantage graphs uses an ordinal scale (grade range, 0-5). We do In higher grades, possible incorrect Cataracts and media opacities retinal nerve fiber layer thickness or limit quality not recommend OCT in all patients with papilledema but total retinal thickness borders believe it may be useful to confirm results when diagno- More patient cooperation required Requires pupil dilation sis is challenging. OCT may be especially useful when No algorithm for optic disc edema Subjective and dependent on there is uncertainty about the presence of optic disc edema. experience We are investigating its use in evaluating disc edema Various artifacts such as those induced by poor centering, myopia, or change over time, and good correlation between photo- movement may not be obvious and graphic grading and OCT analysis is encouraging. Our may interfere with interpretation ability to measure high-grade papilledema should be im- Increased variability and measurement proved with new segmentation algorithms providing more failure at higher grades robust software analysis of disc edema in conjunction with higher-quality images, which are easier to obtain with spectral-domain OCT. Current OCT measurement can improve OCT, fundus photographs will likely remain an be useful as an adjunct to clinical staging. important and reliable method for the assessment of disc edema because of their availability, use among multiple medical disciplines, and few but obvious artifacts, as well Submitted for Publication: January 8, 2009; final revi- as the ability of the examiner to individually assess edema sion received September 2, 2009; accepted October 5, using multiple cues. 2009. Our study has several limitations. Our sample size is Correspondence: Michael Wall, MD, Department of Oph- small, especially at the higher papilledema grades. Mea- thalmology and Visual Sciences, Carver School of Medi- surement error can occur with OCT and with assessment cine, University of Iowa, 200 Hawkins Dr, Iowa City, IA of fundus photographs, and OCT algorithm failure rates 52242 ([email protected]). can become significant with high grades of papilledema. Financial Disclosure: None reported. This study demonstrates that OCT and MFS are Funding/Support: This study was supported by a post- complementary methods that can be used to follow up doctoral fellowship grant from Fight for Sight (Dr Scott), patients with papilledema. However, OCT failure rates by merit and rehabilitation grants from the Department increase as disc edema increases, suggesting that with cur- of Veterans Affairs (Drs Kardon and Wall), and by an un- rent algorithms OCT may be more useful at lower grades restricted grant from Research to Prevent Blindness.

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Announcement

David H. Abramson, MD, was given a tenure appoint- ment at Memorial Sloan-Kettering Cancer Center, where he is the first chief of the Ophthalmic Oncology Ser- vice. He is the first ophthalmologist to ever receive tenure and is presently a professor in the departments of surgery, pediatrics, and radiation oncology.

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