A 5-year-old girl with a history of headaches and possible optic atrophy was referred for neuro-ophthalmologic evaluation. She was born at term and neurodevelopmentally normal. Visual acuity was 20/20, and cycloplegic refraction was +1.0, for each eye. Both pupils reacted briskly to light with no afferent pupillary defect. The right optic disc showed a larger optic cup and relative temporal pallor (Figure). Close examination revealed megalopapilla, with the right optic disc slightly larger than the left (Figure). This size disparity was confirmed using optical coherence tomography, which showed a normal retinal nerve fiber layer thickness in both eyes.
Jung J, Brodsky MC. Megalopapilla Simulating Pediatric Optic Atrophy. JAMA Ophthalmol. 2016;134(5):e155037. doi:10.1001/jamaophthalmol.2015.5037