To Tap or Not to Tap? A Still Unanswered Question for Lumbar Puncture and Treatment Strategies in Asymptomatic Pediatric Papilledema: A Narrative Review

Abstract

Papilledema is a potentially vision-threatening finding in children, often diagnosed during routine ophthalmological evaluation in asymptomatic subjects, which requires prompt diagnostic evaluation to exclude intracranial pathology. The available literature suggests that a significant proportion of cases with confirmed idiopathic intracranial hypertension (IIH) may present without headache or other manifestations of increased intracranial pressure. Current diagnostic criteria for pediatric IIH include lumbar puncture (LP) as a mandatory step following neuroimaging. However, the invasive nature of this procedure raises critical questions regarding the identification of patients who truly require this investigation. Indeed, the challenge of distinguishing true papilledema from pseudopapilledema represents the critical diagnostic prerequisite, requiring an expert pediatric neuro-ophthalmologist to ensure appropriate patient selection and avoid unnecessary tests. Evidence regarding the management of asymptomatic IIH is limited. Most published cohorts report treatment with acetazolamide despite the absence of symptoms, probably based on concerns regarding potential visual deterioration rather than prospective data. Currently, data from pediatric populations characterizing the natural history of untreated patients are lacking, and there is no consensus regarding treatment duration, tapering strategies, or long-term follow-up for this group. This narrative review summarizes the current literature on the diagnostic and therapeutic strategies for asymptomatic pediatric papilledema. It focuses on the role of lumbar puncture, the importance of differentiating papilledema from pseudopapilledema, and the uncertainties surrounding treatment decisions. Nevertheless, significant knowledge gaps persist regarding the optimal management of these patients, highlighting the need for prospective studies.