Diagnostic Utility of Paton’s Folds and Quantitative OCT Metrics in Pediatric Papilledema

Summary

Pediatric papilledema: Presence of Paton’s folds is specific for papilledema, BUT important to incorporate quantitative OCT metrics. Retrospective, 84 eyes.

Abstract

Purpose: We evaluated the diagnostic accuracy of peripapillary retinal folds (RFs) and peripapillary wrinkling (PPW) in distinguishing papilledema (PE) from pseudopapilledema (PPE) in pediatric patients using spectral-domain OCT (SD-OCT). We also identified diagnostic threshold values for retinal nerve fiber layer (RNFL) thickness and optic nerve head volume (ONHV).

Design: Single-center, hospital and clinic-based, retrospective, cross-sectional study.

Participants: We included 84 eyes from 42 pediatric patients with PE and 92 eyes from 46 pediatric patients with PPE.

Methods: Two masked ophthalmologists (H.V. and D.R.) independently reviewed transverse and en face SD-OCT images to assess for RF and PPW. We manually segmented retinal layers and measured RNFL thickness and ONHV. We performed receiver operating curve (ROC) analysis with area under the curve (AUC) to determine optimal diagnostic thresholds. We assessed inter-rater reliability using Cohen’s kappa.

Main outcome measures: Sensitivity and specificity for RF and PPW; optimal diagnostic thresholds for RNFL and ONHV in distinguishing PE from PPE in pediatric patients.

Results: We observed RFs or PPW in 90.2% of PE eyes and 38.6% of PPE eyes (P < 0.0001). Retinal folds demonstrated higher sensitivity (79.2%) but lower specificity (67.4%), whereas PPW showed higher specificity (92.9%) and lower sensitivity (43.5%) in distinguishing PE from PPE in pediatric patients. Transverse OCT had the highest probability of detecting RFs as a marker for PE, whereas en face OCT was more reliable at detecting PPW. Receiver operating characteristic analysis identified optimal PE screening thresholds of ≥163 μm for RNFL (AUC = 0.908) with 78% sensitivity and 93% specificity and a threshold of ≥5.43 mm3 for ONHV (AUC = 0.855) with 73% sensitivity and 90% specificity. Inter-rater agreement was higher for RF on transverse OCT (κ = 0.61) and higher for PPW on en face OCT (κ = 0.54).

Conclusions: Peripapillary wrinkling is specific to PE in pediatric patients and an excellent rule-in tool. Transverse SD-OCT reliably detects Paton’s folds, particularly RF. However, the limited specificity of RF and higher inter-rater variability of rare, subtle findings underscore the importance of incorporating quantitative OCT metrics. Retinal nerve fiber layer thickness and ONHV offer strong discriminative power and objective thresholds to support clinical decision-making. In borderline cases, clinicians can improve diagnostic confidence by integrating fold detection with RNFL and ONHV analysis, additional ancillary testing, and clinical history with exam to create a more accurate, noninvasive approach to distinguish PE from PPE in children.