Papilloedema and optic nerve disorders: Viva

This is a branching oral built to probe the reasoning that holds the neuroimaging before the lumbar puncture at the centre, the Friedman criteria and the Frisén grading, and to expose the candidate who has memorised the headline without the safety-critical corners. The questions escalate from the framing to the neuroimaging, the Friedman criteria, the treatment pathway and the optic neuritis, with the deliberate probes into the antibody-mediated disease and the surgery. ^[1]

Opening question: framing the problem

The examiner opens with the headache and the bilateral disc swelling and asks: how do you frame this problem in a single sentence, and what is your first step? ^[1]

A strong answer names the bilateral disc swelling as the papilloedema of the raised intracranial pressure until proven otherwise, and states that the first step is the urgent neuroimaging. ^[1][2]

Model answer. This child has the papilloedema of the raised intracranial pressure until proven otherwise, and the first step is the urgent magnetic resonance imaging with the venography to exclude the tumour, the hydrocephalus and the venous sinus thrombosis, because the lumbar puncture must not precede the neuroimaging in case of the obstructed flow. ^[1]

Probe one: the neuroimaging and the lumbar puncture

The examiner presses: why the neuroimaging before the lumbar puncture, and how is the opening pressure measured? ^[2]

A strong answer explains the safety and the technique. The neuroimaging precedes the lumbar puncture because the blind lumbar puncture in the obstructed cerebrospinal fluid can cause the fatal herniation, and the magnetic resonance imaging with the venography excludes the mass, the hydrocephalus and the venous sinus thrombosis. The lumbar puncture is performed in the lateral decubitus position with the child relaxed and the legs extended, and the opening pressure is measured with the manometer before the fluid is removed, and the value above two hundred and eighty millimetres of cerebrospinal fluid is the threshold for the raised pressure in the child. The cerebrospinal fluid is analysed for the cells, the protein and the glucose to exclude the meningitis and the inflammation. ^[1][3]