COPHy 2024: Should all patients with idiopathic intracranial hypertension have a lumbar puncture?

Andrew G. Lee, MD, sat down with Modern Retina to outline his perspective on why not all patients with idiopathic intracranial hypertension should have a lumbar puncture. Lee shares some of the key takeaways from his presentation at The 15th Annual Congress on Controversies in Ophthalmology in Athens, Greece, with Group Editorial Director Sheryl Stevenson.

Video Transcript

Editor's note - This transcript has been edited for clarity.

Sheryl Stevenson: We are joined today by Dr. Andrew G. Lee, who is among the faculty at this year's Congress on Controversies in Ophthalmology in Athens, Greece. Welcome to you. It's great to see you again! And we'd love to just hear a little bit about your side of the presentation. I know you're providing the 'no' perspective of the topic, regarding should all patients with idiopathic intracranial hypertension [IIH] have a lumbar puncture [LP]? What can you tell us about your talk today?

Andrew G. Lee, MD: So it is controversial whether a spinal tap needs to be performed in idiopathic intracranial hypertension, but it's a little bit of a misnomer because idiopathic means you already did the spinal tap. So it's kind of a controversy because you really can't make the diagnosis of idiopathic until you've done a spinal tap. But of course, in the real world, some patients refuse to have a spinal tap, or they can't have one, or they're on aspirin, or some other reason that they can't really have a spinal tap. And some patients, despite your best efforts, you can't get the spinal tap. You're sticking the needle in and nothing is coming out.

So the question is, should all patients have it? And even though all patients should be talked to about it, not all patients are going to want to do it, not all patients can do it. And even to the patients who you do do it on, not all patients get any results out. And so the 'no' side is really more dealing with the real world.

In the theoretic world, of course, we would want to have as much data as we can. But in the real world, sometimes not all patients with IIH have a lumbar puncture. And clinicians need to know what to do with that situation. And so, even though we would like to have a spinal tap on all these people, even if you don't have an LP, if it looks like idiopathic intracranial hypertension, we would treat it as such, as long as they don't have any atypical features, or have progression or unusual findings. You probably can get away with no spinal tap on those people as long as they get better. So the teaching point shouldn't be we shouldn't do it, we should try. But when you can't get it, you just have to make do with what you have.

I would just emphasize that the whole reason controversies are controversies is because they're controversial. And my dad would say: If it quacks like a duck, and flies like a duck, and looks like a duck, it's probably a duck. And so if it looks like, quacks like, and acts like idiopathic intracranial hypertension, and you can't get an LP, or they won't do an LP, or you couldn't get the information, then just treat it as if it's IIH, and only if it's getting worse or progressing. Then you can say, okay, you got to have it, no matter what you're saying. But I think a lot of times we do things and we don't actually need to do it.