Using Optical Coherence Tomography in Pediatric Neuro-ophthalmology

Optical coherence tomography (OCT) has transformed adult neuro-ophthalmology, but pediatric adoption has lagged because of perceived technical, financial, and practical barriers. This chapter provides a pragmatic framework for integrating OCT into pediatric and pediatric neuro-ophthalmology clinics, emphasizing how to obtain reliable images in awake children and how to interpret them. We first review technical aspects of tabletop and handheld OCT in children, including positioning, fixation strategies, and when to prioritize single-line macular or optic nerve head B-scans over full segmented protocols. We then outline key clinical modalities: single-line foveal scans for "in vivo histology" and ganglion cell layer/inner nuclear layer (GCL/INL) ratio screening; single-line optic nerve head (ONH) scans to assess Bruch membrane contour and opening size; ONH cube maps for papilledema versus pseudopapilledema; macular cube maps with segmentation to detect retinotopic patterns of GCL loss; and strategies to correct RNFL interpretation for axial length. Using a structured table-based approach, we show how combined RNFL and GCL measurements narrow the differential diagnosis and guide urgency and systemic workup in children with decreased vision and normal, swollen, or atrophic optic nerves. Disease-focused sections illustrate OCT applications in papilledema, pseudopapilledema, optic neuritis, neuroretinitis, optic pathway glioma, optic atrophy (including INL microcysts), infantile nystagmus, and congenital optic nerve anomalies. Throughout, we highlight pitfalls such as pseudonormalization of the RNFL, segmentation errors in high-grade edema or anomalous discs, and misinterpretation in highly ametropic eyes. The chapter aims to make OCT a routine, child-friendly extension of the neuro-ophthalmic exam.