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Similar to examination for retinal hemorrhages, evaluation of
the optic nerve is often difficult in pediatric patients, particularly
infants and toddlers. In older children, examination of the nerve may
be part of the routine well-child examination, or may be performed
due to specific symptoms (such as headache). The presence of papilledema
requires prompt evaluation, including neuroimaging and consultation
with a neurologist. If the patient has an abnormal-appearing nerve,
but no symptoms of increased intracranial pressure, referral to
a pediatric ophthalmologist should be considered to evaluate for
pseudopapilledema, which could obviate the need for further extensive testing.
Most children with other abnormal optic nerve findings should be
referred to a pediatric ophthalmologist.
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What Shouldn’t
Be Missed
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Optic nerve hypoplasia is a frequent cause of very poor vision
and nystagmus in infants. Due to the difficulty of direct ophthalmoscopic
evaluation of the optic nerves in infants with nystagmus, such patients
require referral to a pediatric ophthalmologist. Optic nerve hypoplasia
may be associated with pituitary abnormalities, and these patients
may be unable to mount a normal stress response, potentially causing
severe problems during even mild illnesses. This possibility should be
kept in mind until the patient is evaluated by an endocrinologist.
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Papilledema may occur in patients with idiopathic intracranial
hypertension. In children, this is most commonly associated with ...