Neurosurgery papilledema check?

[ESTJ245]

My program seems to have frequent consults from neurosurgery for evaluating to see if a patient has papilledema (even when they don't have any vision changes or any symptom whatsoever). I would think that they should be able to do this themselves.
I was just wondering if residents at other ophtho programs also experience this or if this is abnormal. Thoughts?

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[Little Green Mensch]

It's pretty common at my hospital to ask for Ophtho eval, and shunt patients do frequently complain of vision symptoms in failure. Finding papilledema is also a nice way to save someone a shunt tap (which risks damaging the shunt valve or introducing infection) or lumbar puncture; in someone who's awake and interactive, a dilated eye exam is reasonable and has much greater sensitivity than an ophthalmoscope.

 

[increscence]

Agreed. It's pretty hard for non-ophthalmologists to check the nerves through undilated pupils. Honestly, even I have trouble with it sometimes. It makes sense to get an ophtho consult in this case.

In residency, I got annoyed with all the consults that I deemed 'stupid'. Stat inpatient consult in the middle of the night for subconj heme or ventilator chemosis, bedside consults for K-F rings in patients being worked up for Wilson's, endophthalmitis checks for asymptomatic patients who had a positive fungal culture in one of two tubes that was probably a contaminant anyway.

But now that I'm in practice, I get it, and I'm not annoyed at all. I know that most people don't have great ophtho backgrounds, and they are legit just doing what they think is right for the patient.

I'm much more annoyed by the culture of medicine that says that educating your colleagues (e.g., please stop prescribing topical antibiotics for pink eye and subconj heme, Restasis as a first-line for dry eye, AREDS2 vitamins for any kind of eye problem) is a sign of pushback and disrespect.

 

[orbitsurgMD]

It is appropriate. Papilledema can be subtle, and having resources like OCT and eye lane equipment as well as perimetry are good reasons to consult. This is an important skill in practice development. Learn it.

 

[dantt]

In residency, I got annoyed with all the consults that I deemed 'stupid'. Stat inpatient consult in the middle of the night for subconj heme or ventilator chemosis, bedside consults for K-F rings in patients being worked up for Wilson's, endophthalmitis checks for asymptomatic patients who had a positive fungal culture in one of two tubes that was probably a contaminant anyway.

But now that I'm in practice, I get it, and I'm not annoyed at all. I know that most people don't have great ophtho backgrounds, and they are legit just doing what they think is right for the patient.

Colleagues out in the real world are much less pushy about the stat consults in the middle of the night for subconj heme, K-F rings for Wilson's workup, etc and are much more reasonable about their requests. Aggressive consult requests will only lead to continuing decreased availability of inpatient ophthalmology consultation.

I had a consult asking to check for spontaneous venous pulsations.

 

[pianist]

I also agree it is a reasonable request, commonly done during my residency. However, important to know that increased
ICP can be present in the absence of papilledema.

 

[Equality]

Colleagues out in the real world are much less pushy about the stat consults in the middle of the night for subconj heme, K-F rings for Wilson's workup, etc and are much more reasonable about their requests. Aggressive consult requests will only lead to continuing decreased availability of inpatient ophthalmology consultation.

I had a consult asking to check for spontaneous venous pulsations.

I had a consult to visit a immobile patient's home to refract them for glasses because they "can't go to an optometrist."

 

[Etorphine]

good luck. with that

 

[The Doctor]

It's a common and important consult. As a resident, you're there to learn so I would accept all of these consults as opportunities to practice your skills. Same thing with fungal endophthalmitis rule-outs. I definitely wouldn't offer any pushback as a trainee but after you've finished training, there is more leeway with working things into clinic later when there is no true urgent reason to see a patient in the hospital. If there is no urgent need, I much prefer a slit lamp exam and access to my B-scan and OCT and camera in clinic for these evaluations. If you're using an indirect a lower diopter lens such as the 14 diopter lens can help achieve better magnification and thus stereopsis. Neurologists send me patients all the time to check for papilledema, and it's an important skill because I have unfortunately seen many patients rushed to the hospital by optometrists for pseudopapilledema and subjected to unnecessary workup. There are many subtleties such as tilted optic discs, crowded discs in in hyperopia, optic disc drusen, chronic changes from prior disc edema. You can consider checking ONH OCT to look for RNFL edema and an FA to eval for true disc edema. When in doubt a good history about transient visual obscurations and pulsatile tinnitus and headaches can help contribute to your degree of suspicion. We did a poster / case series in residency about children with ICP monitoring or ICP measurement and it's fairly uncommon to have true papilledema in the absence of symptoms of elevated ICP even if the disc looks unusual.

 

[Anti-PD1]

I’m a neurosurgery resident and often am the one calling this consult.

I’ve talked my attendings out of an ophtho consult for papilledema when I know I’m going to do an LP anyway (it’s fast, I get a number)

All the above reasons are why we ask, it also lets us compare disc edema before surgery and in the outpatient setting- we send a lot of our skull base/pituitary tumor patients as well to ophthalmology.

A new thing we’re doing for idiopathic intracranial hypertension is transverse venous sinus stenting, it’s saving us from placing shunts and patients report improved vision.

Thanks for all you do!