Spontaneous retinal venous pulsations for evaluation of intracranial pressure after endoscopic third ventriculostomy

Accurate and timely diagnosis of cerebrospinal fluid (CSF) diversion failure, including shunt or ventriculostomy failure, remains challenging. Classically, ophthalmologic evaluation of intracranial pressure (ICP) is based on papilledema, however, spontaneous retinal venous pulsations (SVP) may be another valuable, underutilized tool. We seek to present the case of a patient who underwent endoscopic third ventriculostomy with neuroophthalmological monitoring throughout her post-operative course and provide a brief literature review on the use of SVP for monitoring ICP. Post-operatively, our patient noted improvement of her symptoms and confirmation of successful ventriculostomy on MRI CSF flow studies. There was a monitorable, gradual return of SVP, which supports the use of SVPs as a clinical surrogate to MRI CSF flow study. Literature review suggests that SVP loss is more sensitive than papilledema for elevated ICP, though return of SVP may be delayed in patients post-operatively given CSF dynamics. Based on our clinical findings and literature review, SVP may be an excellent, more sensitive screening test, especially in the absence of papilledema, to evaluate for CSF diversion failure. Ophthalmologic monitoring is cost-effective and non-invasive, and clinical incorporation of SVP could reduce unnecessary testing, hospitalizations, invasive procedures, and patient discomfort. • Accurate and timely diagnosis of CSF diversion failure remains challenging. • Ophthalmologic monitoring is cost-effective and non-invasive. • Spontaneous retinal venous pulsations are valuable to assess intracranial pressure. • Post-ventriculostomy patient shows SVP return correlating with clinical improvement. • SVP may be a more sensitive screening test to evaluate for CSF diversion failure.