Resident Perspectives

Abstract

Assessment of the visual function of partially sighted and blind Canadian youth using the VFQ-25 questionnaire: a resident's perspectivePatient Reported Outcome Measures (PROMs) are tools (typically questionnaires) that measure aspects of illness, functional status or therapeutic effects as reported directly by patients.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar With the movement to make health care more patient centered, PROMs are gaining an increasingly important place in clinical practice and medical research.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar In Ophthalmology, PROMs tend to address one or more of the following domains: vision related quality of life, functional vision, or severity of symptoms like ocular pain.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar,2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google ScholarMany of the conditions leading to childhood visual impairment in high-income countries are not preventable or reversible. In this setting, PROMs can be used to guide rehabilitation efforts to mitigate the effects of visual impairment on social and occupational functioning.2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar It is accepted that children as young as 7 years old can validly and reliably respond to appropriately-designed PROMs.2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar However, it is essential that such PROMs use developmentally appropriate language and assess activities and experiences that are relevant to children.2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar These added methodological challenges mean that few validated PROMs are currently available for use with visually impaired children.3Tadic V. Hogan A. Sobti N. Knowles R.L. Rahi J.S. Patient-reported outcome measures (PROMs) in paediatric ophthalmology: a systematic review.Br J Ophthalmol. 2013; 97: 1369-1381https://doi.org/10.1136/bjophthalmol-2013-303350Crossref PubMed Scopus (28) Google ScholarIn the current issue, Fleming and colleagues evaluate a PROM called the Visual Function Questionnaire (VFQ) among a sample of 47 visually impaired Canadian youth between 8 and 20 years of age.4Fleming N. Farrokhyar F. Sabri K. Assessment of the visual function of partially sighted and blind Canadian youth using the VFQ-25 questionnaire: a preliminary study.Can J Ophthalmol. 2019; 54: 674-677Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The VFQ is the most commonly used vision-related PROM in the world.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar It was developed from focus group discussions involving adults with a variety of eye conditions and is intended to measure the quality of life impacts of “all cause” visual impairment.5Mangione C.M. Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD, and National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire.Arch Ophthalmol. 2001; 119: 1050-1058https://doi.org/10.1001/archopht.119.7.1050Crossref PubMed Scopus (1566) Google Scholar The shortened version of the VFQ includes 25 questions covering: general health, general vision, near and distance vision, peripheral vision, colour vision, driving, role limitations, dependency, social function, and mental health.5Mangione C.M. Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD, and National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire.Arch Ophthalmol. 2001; 119: 1050-1058https://doi.org/10.1001/archopht.119.7.1050Crossref PubMed Scopus (1566) Google ScholarDespite having advanced vision loss (most with acuities of 20/200 or worse), the children and youth in Fleming and colleagues’ sample reported relatively high VFQ-25 scores compared to cohorts of adults with similar levels of acuity. In particular, they reported comparatively high scores in the social functioning and mental health domains. Interestingly, children with congenital or early onset visual impairment reported higher levels of vision related quality of life than those with more recent onset visual impairment, possibly signifying better adaptation or greater acceptance of their levels of visual functioning. A limitation of these findings is that the study did not specifically address whether the VFQ-25 was developmentally appropriate for the age group studied, nor whether the respondents found the items on the questionnaire to be generally relevant to their lives.While further work is necessary to validate the VFQ for use with children, clinicians and researchers wishing to include these types of measures in their work may find helpful information in Tadić and colleagues’ systematic review of PROMs for paediatric ophthalmology3Tadic V. Hogan A. Sobti N. Knowles R.L. Rahi J.S. Patient-reported outcome measures (PROMs) in paediatric ophthalmology: a systematic review.Br J Ophthalmol. 2013; 97: 1369-1381https://doi.org/10.1136/bjophthalmol-2013-303350Crossref PubMed Scopus (28) Google Scholar and in the Patient-Reported Outcome and Quality of life Instruments Database (https://eprovide.mapi-trust.org/about/about-proqolid).Referenced article: https://www.canadianjournalofophthalmology.ca/article/S0008-4182(19)30036-5/fulltext Patient Reported Outcome Measures (PROMs) are tools (typically questionnaires) that measure aspects of illness, functional status or therapeutic effects as reported directly by patients.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar With the movement to make health care more patient centered, PROMs are gaining an increasingly important place in clinical practice and medical research.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar In Ophthalmology, PROMs tend to address one or more of the following domains: vision related quality of life, functional vision, or severity of symptoms like ocular pain.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar,2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar Many of the conditions leading to childhood visual impairment in high-income countries are not preventable or reversible. In this setting, PROMs can be used to guide rehabilitation efforts to mitigate the effects of visual impairment on social and occupational functioning.2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar It is accepted that children as young as 7 years old can validly and reliably respond to appropriately-designed PROMs.2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar However, it is essential that such PROMs use developmentally appropriate language and assess activities and experiences that are relevant to children.2Tadić V. Rahi J.S. One size doesn't fit all: time to revisit patient-reported outcome measures (PROMs) in paediatric ophthalmology?.Eye (Lond). 2017; 31: 511-518https://doi.org/10.1038/eye.2016.316Crossref PubMed Scopus (10) Google Scholar These added methodological challenges mean that few validated PROMs are currently available for use with visually impaired children.3Tadic V. Hogan A. Sobti N. Knowles R.L. Rahi J.S. Patient-reported outcome measures (PROMs) in paediatric ophthalmology: a systematic review.Br J Ophthalmol. 2013; 97: 1369-1381https://doi.org/10.1136/bjophthalmol-2013-303350Crossref PubMed Scopus (28) Google Scholar In the current issue, Fleming and colleagues evaluate a PROM called the Visual Function Questionnaire (VFQ) among a sample of 47 visually impaired Canadian youth between 8 and 20 years of age.4Fleming N. Farrokhyar F. Sabri K. Assessment of the visual function of partially sighted and blind Canadian youth using the VFQ-25 questionnaire: a preliminary study.Can J Ophthalmol. 2019; 54: 674-677Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The VFQ is the most commonly used vision-related PROM in the world.1Denniston A.K. Kyte D. Calvert M. Burr J.M. An introduction to patient-reported outcome measures in ophthalmic research.Eye (Lond). 2014; 28: 637-645https://doi.org/10.1038/eye.2014.41Crossref PubMed Scopus (37) Google Scholar It was developed from focus group discussions involving adults with a variety of eye conditions and is intended to measure the quality of life impacts of “all cause” visual impairment.5Mangione C.M. Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD, and National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire.Arch Ophthalmol. 2001; 119: 1050-1058https://doi.org/10.1001/archopht.119.7.1050Crossref PubMed Scopus (1566) Google Scholar The shortened version of the VFQ includes 25 questions covering: general health, general vision, near and distance vision, peripheral vision, colour vision, driving, role limitations, dependency, social function, and mental health.5Mangione C.M. Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD, and National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire.Arch Ophthalmol. 2001; 119: 1050-1058https://doi.org/10.1001/archopht.119.7.1050Crossref PubMed Scopus (1566) Google Scholar Despite having advanced vision loss (most with acuities of 20/200 or worse), the children and youth in Fleming and colleagues’ sample reported relatively high VFQ-25 scores compared to cohorts of adults with similar levels of acuity. In particular, they reported comparatively high scores in the social functioning and mental health domains. Interestingly, children with congenital or early onset visual impairment reported higher levels of vision related quality of life than those with more recent onset visual impairment, possibly signifying better adaptation or greater acceptance of their levels of visual functioning. A limitation of these findings is that the study did not specifically address whether the VFQ-25 was developmentally appropriate for the age group studied, nor whether the respondents found the items on the questionnaire to be generally relevant to their lives. While further work is necessary to validate the VFQ for use with children, clinicians and researchers wishing to include these types of measures in their work may find helpful information in Tadić and colleagues’ systematic review of PROMs for paediatric ophthalmology3Tadic V. Hogan A. Sobti N. Knowles R.L. Rahi J.S. Patient-reported outcome measures (PROMs) in paediatric ophthalmology: a systematic review.Br J Ophthalmol. 2013; 97: 1369-1381https://doi.org/10.1136/bjophthalmol-2013-303350Crossref PubMed Scopus (28) Google Scholar and in the Patient-Reported Outcome and Quality of life Instruments Database (https://eprovide.mapi-trust.org/about/about-proqolid). Referenced article: https://www.canadianjournalofophthalmology.ca/article/S0008-4182(19)30036-5/fulltext Control is key: Predicting surgical success in intermittent exotropiaIntermittent exotropia is a common form of childhood strabismus that is usually seen in association with good visual acuity and initial development of binocular vision. Surgical treatment is common, though the precise indications for and timing of intervention are variable. One reason for this is that outcomes are often unpredictable. Efforts to correlate pre-operative factors such as age, angle of deviation, refractive error, fusional ranges, or stereoacuity with surgical success rates have yielded disappointing or conflicting results.1Buck D. Powell C.J. Sloper J.J. Taylor R. Tiffin P. Clarke MP; Improving Outcomes in Intermittent Exotropia (IOXT) Study group. Surgical intervention in childhood intermittent exotropia: current practice and clinical outcomes from an observational cohort study.Br J Ophthalmol. 2012; 96: 1291-1295Crossref PubMed Scopus (24) Google Scholar,2Zou D. Casafina C. Whiteman A. Jain S. Predictors of surgical success in patients with intermittent exotropia.J AAPOS. 2017; 21: 15-18Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In this issue, Moon and colleagues describe a simple test for predicting surgical outcomes in intermittent exotropia.3Moon Y. Kim H. Kim D.H. Lim H.Y. LACTOSE control scoring helps predict surgical outcomes for childhood intermittent exotropia.Can J Ophthalmol. 2019; 54: 659-663Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarThe authors describe a large cohort of 350 South Korean patients with basic type intermittent exotropia undergoing bilateral lateral rectus recession by a single surgeon for an angle of at least 20 prism diopters (PD). They describe a novel scoring system based on degree of control, which is abbreviated as LACTOSE: Look And Cover, then Ten seconds of Observation Scale for Exotropia. A maximum score of 4 was assigned if exotropia was manifest in 10 seconds of fixation. If not, an alternate cover test was performed for 10 seconds before the patient was asked to refixate, then a score from 0 (exophoria) to 3 (exotropia manifest for the entire 10 seconds post-alternate cover testing) was assigned. Two scores were done three months apart by a single surgeon, who was masked to their previous score.Surgical success was defined as an alignment between 10 PD of exodeviation and 5 PD of esodeviation at both distance and near at one year. In the success group, average LACTOSE scores were 3.11 ± 0.89 at distance and 1.94 ± 1.11 at near, compared with 3.54 ± 0.65 and 2.38 ± 1.11 respectively in the failure group. This difference was statistically significant between the two groups while age, angle of deviation, stereoacuity, and refraction were not.This work describes a new tool for strabismus surgeons that can be used when attempting to answer a question that is constantly asked by parents: will surgery be effective for my child? It is quick, easy to perform in clinic, and shows promise in discriminating between the two categories of surgical success versus failure. It does not appear to capture all of the elements that predict success, as many patients with a maximum score of 4 went on to have good post-operative outcomes. It would be interesting to know whether LACTOSE scores also correlate with outcomes in a natural history study of untreated exotropia.Though an impressive cohort, only 169 patients (48%) completed a follow-up assessment at 1 year and were included in the analysis of surgical success. Decompensation often occurs many years post-operatively, and so reassessment of the study patients even further out would be informative. The overall one-year success rate reported was excellent (78%), however, was defined on pure motor parameters. Considering sensory outcomes as well as motor further characterizes functional vision and results in a much smaller proportion of patients being classified as a good surgical result,4Pineles S.L. Ela-Dalman N. Zvansky A.G. Yu F. Rosenbaum A.L. Long-term results of the surgical management of intermittent exotropia.J AAPOS. 2010; 14: 298-304Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar potentially altering study conclusions substantially.Surgeons should consider evaluating and documenting degree of control in patients with intermittent exotropia pre-operatively, and the authors provide an efficient means to do so. This work adds to the understanding of this common but poorly understood form of strabismus and opens up exciting possibilities for future research in predicting outcomes and influencing surgical planning.Referenced article: https://www.canadianjournalofophthalmology.ca/article/S0008-4182(18)31206-7/fulltext Intermittent exotropia is a common form of childhood strabismus that is usually seen in association with good visual acuity and initial development of binocular vision. Surgical treatment is common, though the precise indications for and timing of intervention are variable. One reason for this is that outcomes are often unpredictable. Efforts to correlate pre-operative factors such as age, angle of deviation, refractive error, fusional ranges, or stereoacuity with surgical success rates have yielded disappointing or conflicting results.1Buck D. Powell C.J. Sloper J.J. Taylor R. Tiffin P. Clarke MP; Improving Outcomes in Intermittent Exotropia (IOXT) Study group. Surgical intervention in childhood intermittent exotropia: current practice and clinical outcomes from an observational cohort study.Br J Ophthalmol. 2012; 96: 1291-1295Crossref PubMed Scopus (24) Google Scholar,2Zou D. Casafina C. Whiteman A. Jain S. Predictors of surgical success in patients with intermittent exotropia.J AAPOS. 2017; 21: 15-18Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In this issue, Moon and colleagues describe a simple test for predicting surgical outcomes in intermittent exotropia.3Moon Y. Kim H. Kim D.H. Lim H.Y. LACTOSE control scoring helps predict surgical outcomes for childhood intermittent exotropia.Can J Ophthalmol. 2019; 54: 659-663Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The authors describe a large cohort of 350 South Korean patients with basic type intermittent exotropia undergoing bilateral lateral rectus recession by a single surgeon for an angle of at least 20 prism diopters (PD). They describe a novel scoring system based on degree of control, which is abbreviated as LACTOSE: Look And Cover, then Ten seconds of Observation Scale for Exotropia. A maximum score of 4 was assigned if exotropia was manifest in 10 seconds of fixation. If not, an alternate cover test was performed for 10 seconds before the patient was asked to refixate, then a score from 0 (exophoria) to 3 (exotropia manifest for the entire 10 seconds post-alternate cover testing) was assigned. Two scores were done three months apart by a single surgeon, who was masked to their previous score. Surgical success was defined as an alignment between 10 PD of exodeviation and 5 PD of esodeviation at both distance and near at one year. In the success group, average LACTOSE scores were 3.11 ± 0.89 at distance and 1.94 ± 1.11 at near, compared with 3.54 ± 0.65 and 2.38 ± 1.11 respectively in the failure group. This difference was statistically significant between the two groups while age, angle of deviation, stereoacuity, and refraction were not. This work describes a new tool for strabismus surgeons that can be used when attempting to answer a question that is constantly asked by parents: will surgery be effective for my child? It is quick, easy to perform in clinic, and shows promise in discriminating between the two categories of surgical success versus failure. It does not appear to capture all of the elements that predict success, as many patients with a maximum score of 4 went on to have good post-operative outcomes. It would be interesting to know whether LACTOSE scores also correlate with outcomes in a natural history study of untreated exotropia. Though an impressive cohort, only 169 patients (48%) completed a follow-up assessment at 1 year and were included in the analysis of surgical success. Decompensation often occurs many years post-operatively, and so reassessment of the study patients even further out would be informative. The overall one-year success rate reported was excellent (78%), however, was defined on pure motor parameters. Considering sensory outcomes as well as motor further characterizes functional vision and results in a much smaller proportion of patients being classified as a good surgical result,4Pineles S.L. Ela-Dalman N. Zvansky A.G. Yu F. Rosenbaum A.L. Long-term results of the surgical management of intermittent exotropia.J AAPOS. 2010; 14: 298-304Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar potentially altering study conclusions substantially. Surgeons should consider evaluating and documenting degree of control in patients with intermittent exotropia pre-operatively, and the authors provide an efficient means to do so. This work adds to the understanding of this common but poorly understood form of strabismus and opens up exciting possibilities for future research in predicting outcomes and influencing surgical planning. Referenced article: https://www.canadianjournalofophthalmology.ca/article/S0008-4182(18)31206-7/fulltext Papilledema in the pediatric ambulatory clinicPapilledema is a term reserved for optic nerve edema secondary to raised intracranial pressure (ICP). In children, elevated ICP is considered when a lumbar puncture opening pressure is ˃28cm H2O.1Avery R.A. Shah S.S. Licht D.J. et al.Reference range for cerebrospinal fluid opening pressure in children.N Engl J Med. 2010; 363: 891-893Crossref PubMed Scopus (185) Google Scholar While a diagnosis of true papilledema is rare in pediatric patients referred to an ambulatory ophthalmology clinic with a suspicion of papilledema,2Chen J.J. Bhatti M.T. Papilledema.Int Ophthalmol Clin. 2019; 59 (Summer): 3-22Crossref PubMed Scopus (9) Google Scholar a careful fundus examination is warranted to avoid missing a potentially life-threatening disease process.In this issue, Hyde et al. retrospectively examined the etiologies of confirmed cases of papilledema in a pediatric population from 1996 to 2018. Their study population included primarily ambulatory outpatients from two separate sites. Interestingly, the literature is scarce for analyses of the underlying causes of true papilledema in this patient population. The authors identified 38 patients with papilledema from diagnostic codes and discovered that the most common etiologies were idiopathic intracranial hypertension (IIH) (42%), craniosynostoses (18%), and intracranial tumors (16%).3Hyde R.A. Mocan M.C. Sheth U. Kaufman L.M. Evaluation of the underlying causes of papilledema in children.Can J Ophthalmol. 2019; 54: 653-658Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Together, these causes accounted for over 75% of cases of papilledema in children. Strikingly, the authors report that only 1 of the 38 patients had been referred specifically to rule out papilledema. The remaining cases included primary hydrocephalus and infectious and inflammatory etiologies, among others.3Hyde R.A. Mocan M.C. Sheth U. Kaufman L.M. Evaluation of the underlying causes of papilledema in children.Can J Ophthalmol. 2019; 54: 653-658Abstract Full Text Full Text PDF PubMed Scopus (2) Google ScholarThis article highlights several concepts that are important for both residents and ophthalmologists practicing in community settings to consider. First, IIH accounts for nearly half of all cases of papilledema in this pediatric population. While headache and diplopia are the most common symptoms, over one-third of patients are asymptomatic.3Hyde R.A. Mocan M.C. Sheth U. Kaufman L.M. Evaluation of the underlying causes of papilledema in children.Can J Ophthalmol. 2019; 54: 653-658Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In addition, the nature of headache symptoms varies widely in children with IIH where, for example, the headaches may be constant or episodic, and focal or diffuse.4Barmherzig R. Szperka C.L. Pseudotumor Cerebri Syndrome in Children.Curr Pain Headache Rep. 2019; 23 (Jul 10): 58Crossref PubMed Scopus (14) Google Scholar Second, although the authors admit that patients with craniosynostosis may have been over-represented in their study due to local referral patterns, routine ophthalmic evaluation of these patients is important since none of them had presented with signs of elevated ICP. Third, the percentage of patients with papilledema due to an intracranial mass is not insignificant, even in an ambulatory clinic. As a result, urgent neuroimaging is prudent when papilledema is suspected.Finally, although not specifically highlighted by the authors, over one-third of the patients in their study with papilledema had strabismus at presentation. A cranial nerve six palsy is the most common cranial nerve palsy associated with elevated ICP;5Wright H.E. Brodsky M.C. Chacko J.G. Ramakrishnaiah R.H. Phillips P.H. Diplopia is better than no plopia.Surv Ophthalmol. 2017; 62 (Nov - Dec): 875-881Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar however, comitant esotropia, exotropia, and other cranial nerve palsies were also identified in this study.3 This association reiterates the importance of a complete fundus examination, including specific attention to the optic nerves, in patients presenting acutely with either comitant or incomitant strabismus.Referenced article: https://www.canadianjournalofophthalmology.ca/article/S0008-4182(18)31313-9/fulltext Papilledema is a term reserved for optic nerve edema secondary to raised intracranial pressure (ICP). In children, elevated ICP is considered when a lumbar puncture opening pressure is ˃28cm H2O.1Avery R.A. Shah S.S. Licht D.J. et al.Reference range for cerebrospinal fluid opening pressure in children.N Engl J Med. 2010; 363: 891-893Crossref PubMed Scopus (185) Google Scholar While a diagnosis of true papilledema is rare in pediatric patients referred to an ambulatory ophthalmology clinic with a suspicion of papilledema,2Chen J.J. Bhatti M.T. Papilledema.Int Ophthalmol Clin. 2019; 59 (Summer): 3-22Crossref PubMed Scopus (9) Google Scholar a careful fundus examination is warranted to avoid missing a potentially life-threatening disease process. In this issue, Hyde et al. retrospectively examined the etiologies of confirmed cases of papilledema in a pediatric population from 1996 to 2018. Their study population included primarily ambulatory outpatients from two separate sites. Interestingly, the literature is scarce for analyses of the underlying causes of true papilledema in this patient population. The authors identified 38 patients with papilledema from diagnostic codes and discovered that the most common etiologies were idiopathic intracranial hypertension (IIH) (42%), craniosynostoses (18%), and intracranial tumors (16%).3Hyde R.A. Mocan M.C. Sheth U. Kaufman L.M. Evaluation of the underlying causes of papilledema in children.Can J Ophthalmol. 2019; 54: 653-658Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Together, these causes accounted for over 75% of cases of papilledema in children. Strikingly, the authors report that only 1 of the 38 patients had been referred specifically to rule out papilledema. The remaining cases included primary hydrocephalus and infectious and inflammatory etiologies, among others.3Hyde R.A. Mocan M.C. Sheth U. Kaufman L.M. Evaluation of the underlying causes of papilledema in children.Can J Ophthalmol. 2019; 54: 653-658Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar This article highlights several concepts that are important for both residents and ophthalmologists practicing in community settings to consider. First, IIH accounts for nearly half of all cases of papilledema in this pediatric population. While headache and diplopia are the most common symptoms, over one-third of patients are asymptomatic.3Hyde R.A. Mocan M.C. Sheth U. Kaufman L.M. Evaluation of the underlying causes of papilledema in children.Can J Ophthalmol. 2019; 54: 653-658Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In addition, the nature of headache symptoms varies widely in children with IIH where, for example, the headaches may be constant or episodic, and focal or diffuse.4Barmherzig R. Szperka C.L. Pseudotumor Cerebri Syndrome in C