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Ophthalmic Images
October 13, 2016

Optical Coherence Tomography Imaging of Paton Folds in Papilledema With Retinopathy From Systemic Hypertension

Author Affiliations
  • 1Bolton National Health Service Foundation Trust, Bolton, United Kingdom
JAMA Ophthalmol. 2016;134(10):e162121. doi:10.1001/jamaophthalmol.2016.2121

A man in his 30s with an unremarkable medical history presented with a 2-day history of headache and blurred vision. Visual acuity was 20/20 OD and 20/25 OS. Ophthalmoscopy revealed bilateral papilledema with retinal hemorrhages and nerve fiber layer infarcts. In addition, concentric wrinkles radiating from the left optic disc were observed. The presenting blood pressure was 240/166 mm Hg and, combined with end-organ damage, systemic hypertensive emergency was diagnosed.

Retinal imaging temporal to the disc demonstrated undulating folds in a “hill-valley” or sawtooth pattern involving the superficial layer of the neurosensory retina (Figure). Visual acuity recovered to 20/20 bilaterally with resolution of all retinal folds following control of systemic hypertension by oral medications.

Figure.
A, Infrared reflectance image. B, Raster spectral-domain optical coherence tomographic image. Paton lines/folds are visible as lines/folds temporal to the optic disc and as serial sawtooth wrinkles in the inner retina. There is also intraretinal and subretinal fluid contiguous with the optic disc.

A, Infrared reflectance image. B, Raster spectral-domain optical coherence tomographic image. Paton lines/folds are visible as lines/folds temporal to the optic disc and as serial sawtooth wrinkles in the inner retina. There is also intraretinal and subretinal fluid contiguous with the optic disc.

In 1911, Leslie Paton described retinal folds concentric with the edge of the optic disc in fatal papilledema.1 These eponymous signs are being better appreciated and classified in patients with idiopathic intracranial hypertension modern retinal imaging.2,3

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Article Information

Corresponding Author: Minji Jennifer Kim, BSc(Hons), MBChB, Bolton National Health Service Foundation Trust, Minerva Road, Bolton BL4 0JR, United Kingdom (j.kim@nhs.net).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Paton  L, Holmes  G.  The pathology of papilloedema: a histological study of 60 eyes.  Brain. 1911;33:289-432.Google ScholarCrossref
2.
Sibony  PA, Kupersmith  MJ, Feldon  SE, Wang  JK, Garvin  M; OCT Substudy Group for the NORDIC Idiopathic Intracranial Hypertension Treatment Trial.  Retinal and choroidal folds in papilledema.  Invest Ophthalmol Vis Sci. 2015;56(10):5670-5680.PubMedGoogle ScholarCrossref
3.
Sibony  PA, Kupersmith  MJ; OCT Substudy Group of the NORDIC Idiopathic Intracranial Hypertension Treatment Trial.  “Paton folds” revisited: peripapillary wrinkles, folds, and creases in papilledema.  Ophthalmology. 2016;123(6):1397-1399. PubMedGoogle ScholarCrossref
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