Revisiting the Need for Diagnostic Lumbar Puncture in Idiopathic Intracranial Hypertension

Letters to the Editor Revisiting the Need for Diagnostic Lumbar Puncture in Idiopathic Intracranial Hypertension W e read with interest the recent article in JNO by Margolis et al (1). Their study, although retrospective in nature, challenges current clinical practice, which dictates that all patients with presumed idiopathic intracranial hypertension (IIH) must undergo lumbar puncture (LP) to check opening pressure and to ensure that cerebrospinal fluid (CSF) contents are normal. We also believe that a blanket approach like this often overestimates the perceived benefits of LP and underestimates the potential risks and limitations associated with this procedure. The COVID-19 pandemic forced us to re-evaluate our approach to all aspects of medical care. As a consequence of the increased risk of nosocomial infection from keeping patients in hospital for LP, we questioned whether LP was always necessary in suspected IIH. We concluded that in young obese women with bilateral mild-to-moderate disc edema, good visual function, classic neuroimaging findings and no atypical features, it was not. Margolis et al (1) comprehensively covered the reasons why in expert hands this approach to what they referred to as patients with “typical” IIH does make sense. We would, Patient-Reported Outcomes for Ocular Myasthenia Gravis D e Lott and Ehrlich's recent editorial on PatientReported Outcome Research in Neuroophthalmology comprehensively summarized the important considerations of patient-reported outcomes (PROs) and elegantly highlighted the importance of capturing our patient's experience of living with neuro-ophthalmic disease (1). We concur that the development of relevant PROs for neuro-ophthalmic diseases is much needed and will better support our patient's care and monitoring. Most visionrelated and neurologic-related measures are limited for monitoring ocular motility problems, for example, ocular myasthenia gravis (OMG), and better measures are needed (2). As highlighted by the authors, the National Eye Institute Visual Function Quality of Life (NEI-VFQ) questionnaire poorly captures ocular motility problems. The NEI-VFQ NeuroOphthalmology Supplement was mentioned as a supplement to this for capturing diplopia. However, the questions on diplopia are limited and, in our experience, insufficient to reflect the experience of our patients with OMG, with the characteristic fluctuation of ptosis and diplopia (2). With this in mind, we recently published a new, validated, rating scale for monitoring the severity of OMG (3). This rating scale incorporates a PRO, enabling us to e356 however, like to add another argument that we think is important, namely, the issue of patient autonomy. We believe that to present the need for LP as absolute in all cases of suspected IIH does not meet the standards of informed consent. The data provided by Margolis et al (1) add weight to this view, given LP/CSF results did not change diagnosis or management in any of their 156 typical cases. It follows that it should be considered good practice to discuss the relative merits of LP with all patients with suspected IIH. Specifically, in presumed typical cases, we would advocate presenting LP as an option rather than a necessity. Shelby Ramsamy, MBChB, MRCP, Sumeet Singhal, MBChB, MRCP, MD, Anna M. Gruener, BMBS, MSc Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; and Department of Ophthalmology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom The authors report no conflicts of interest. REFERENCE 1. Margolis MS, DeBusk AA, Moster ML, Falardeau JM, Eggenberger ER, Sergott RC, Van Stavern GP. Lumbar puncture for diagnosis of idiopathic intracranial hypertension in typical patients. J Neuroophthalmol. 2021 41:375–378. capture the severity and fluctuations of patients' symptoms over a 2-week period, to convey the impact of their symptoms on their daily lives more accurately. Through a multicenter collaboration, we continue to use the PRO to monitor patients, particularly timely because in-person visits have been limited with the COVID-19 pandemic, and have plans to validate this through a multicentre study shortly. Sui Hsien Wong, MRCP, Eric R. Eggenberger, DO, Wayne T. Cornblath, MD Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, United Kingdom, Department of Neuro-ophthalmology, Mayo Clinic Jacksonville, Jacksonville, Florida; and Department of Neuro-ophthalmology, University of Michigan, Ann Arbor, Michigan The authors report no conflicts of interest. REFERENCES 1. De Lott LB, Ehrlich JR. Patient-reported outcomes Research in neuro-ophthalmology. J Neuroophthalmol. 2021;41:141–146. 2. Wong SH. Rating scale for ocular myasthenia gravis: a call to action! J Neuroophthalmol. 2018;38:138–139. 3. Wong SH, Eggenberger E, Cornblath W, Xhepa A, Miranda E, Lee H, Burke A, Barnett C. Preliminary findings of a dedicated ocular myasthenia gravis rating scale: the OMGRate. Neuroophthalmology. 2020;44:148–156. Letters to the Editor: J Neuro-Ophthalmol 2023; 43: e356-362 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.