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Clinical Review

Identifying brain tumours in children and young adults

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5844 (Published 09 October 2013) Cite this as: BMJ 2013;347:f5844

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Re: Identifying brain tumours in children and young adults

We read the article "Identifying brain tumours in children and young adults" by Wilne et al (1) with great interest. We agree that healthcare professionals caring for children need to promptly identify the child or young person with a serious underlying condition, and that early diagnosis is crucial.

Recognising when a child might have a space-occupying lesion can be particularly challenging in young children, given the frequent absence of the classic 'red flag' symptoms and their lack of specificity.

We wish to highlight the importance of fundal eye examination in this group of children as papilloedema can precede other signs and symptoms of raised intracranial pressure. Wilne et al showed in their review in 2006 that 18.5% of children diagnosed with brain tumours (37 out of 200 children included in the review) had only cranial nerve signs or papilloedema without other signs (2). Among them, 24% (9 cases) had papilloedema as the only sign on presentation.

Given the challenge of performing ophthalmoscopy, and then the subjectivity of interpreting the appearance of the optic nerve head in children, we would like to bring attention to the emerging role of optical coherence tomography (OCT) in assisting the diagnosing of papilloedema.

Optical coherence tomography (OCT) is a rapid non-invasive imaging modality which has been shown to be useful for evaluating the peripapillary nerve fiber layer (RNFL). OCT has been performed both in normal children (3) and in children with optic nerve head swelling from various disorders (4). The OCT appearance of the optic nerve head when swollen has been well defined, with studies describing increased RNFL thickening, with the nasal RNFL thickness being the most significant factor indicating genuine papilloedema (5).

OCT is an established imaging tool in clinical ophthalmology, and we see an evolving role – in conjunction with standard ophthalmoscopy – in diagnosing papilloedema in children.

References
1. Wilne SH, Dineen RA, Dommett RM, Chu TPC, Walker DA. Identifying brain tumours in children and young adults. BMJ 2013; 347: f5844
2. Wilne SH, Ferris RC, Nathwani A, Kennedy CR. The presenting features of brain tumours: a review of 200 cases. Arch Dis Child 2006; 91: 502-6.
3. Salchow D, Oleynikov Y, Chiang M, Kennedy-Salchow S, Langton K, Tsai J, et al. Retinal nerve fiber layer thickness in normal children measured with optical coherence tomography. Ophthalmology 2006; 113: 786-91.
4. El-Dairi MA, Holgado S, O’Donnell T, Buckley EG, Asrani S, Freedman SF. Optical coherence tomography as a tool for monitoring pediatric pseudotumor cerebri. Journal of AAPOS 2007; 11: 564-70.
5. Lee MK, Woo SJ, Hwang JM. Differentiation of optic nerve head drusen and optic disc edema with spectral-domain optical coherence tomography. Ophthalmology 2011; 118(5): 971-7.

Authorship
1) Sofia Theodoropoulou. Academic clinical fellow in ophthalmology, University of Bristol
2) James R Cameron. Rowling Scholar and honorary consultant ophthalmologist, University of Edinburgh
3) Andrew J Blaikie. Consultant paediatric ophthalmologist, NHS Fife

Competing interests: No competing interests

16 October 2013
Sofia Theodoropoulou
Academic clinical fellow in ophthalmology
James R Cameron, Andrew J Blaikie
University of Bristol
School of Medical Sciences, Bristol. BS8 1TD