Sensitivity of papilledema as a sign of shunt failure in children

PurposePapilledema is considered one of the cardinal ophthalmologic signs of shunt failure. However, the prevalence of papilledema in children with shunt malfunction has not been systematically investigated. The purpose of this study is to determine the sensitivity of papilledema as a sign of shunt failure in children.MethodsA prospective evaluation was undertaken of all children (n = 29; <19 years of age) with surgically confirmed shunt malfunction who were treated at Arkansas Children's Hospital between July 2007 and April 2008. Each child had a dilated fundus examination and/or RetCam photograph while under anesthesia immediately before shunt repair. The optic disk was evaluated for the presence of papilledema and pallor. Intracranial pressure was measured during surgical shunt repair at the discretion of the neurosurgeon.ResultsTwenty-nine patients had surgically confirmed shunt failure. Patient's age ranged from 36 days to 18 years, 8 months. Four patients (14%) had papilledema, and 1 patient had severe optic disk pallor. The remaining 24 patients had flat optic disks. Five patients had flat optic disks despite an intracranial pressure ≥300 mm H2O.ConclusionsPapilledema is not a sensitive sign of shunt failure. Even children with severe elevations in intracranial pressure from shunt malfunction may have flat optic disks. Therefore, physicians that evaluate children with shunts should be aware that a normal optic disk does not preclude shunt malfunction.