Inpatient versus outpatient management of bilateral optic nerve head elevation presentation to a tertiary emergency department.

Introduction: Increased accessibility to fundus cameras has changed the referral pattern for patients with suspected bilateral optic nerve head elevation (BONHE) presenting to emergency departments (EDs). We aim to review the management of these patients to streamline the process. Methods: A retrospective review of patients with suspected BONHE referred to a tertiary centre ED between 2017 and 2022. We collected demographics, referral source, clinical assessment, neuroimaging and retinal imaging results. Final diagnosis and treatment outcomes were compared between those managed as inpatients and those managed as outpatients. Results: 100 patients were referred to the ED with a suspected BONHE. Most were referred by optometrists (54) or general practitioners (17). 54 were admitted (group A) and 38 were discharged from ED (group B). The remaining eight had incomplete records, transferred out of a public health system or self-discharged. The median duration of stay in the ED was 5 hours (IQR 3.45-6.12). The most common diagnosis for both groups was idiopathic intracranial hypertension (IIH). 47 patients at follow-up had moderate to severe IIH and other significant pathologies. For these patients, vision impairment at presentation is the only statistically significant predictor on multivariate analysis (p=0.03). Based on the final diagnoses, 26 out of 48 patients (54.2%) in group A were diagnosed with IIH, with a median duration from presentation to diagnosis of 2 days (IQR 1-4 days). In group B, 8 out of 29 patients (27.5%) were diagnosed with IIH on follow-up, and the median duration from first presentation to diagnosis was 16.8 days (IQR 5.8-57 days). Conclusions: IIH is the most common diagnosis among ED presentations of suspected BONHE in our study. We proposed a triage system for prompt management of BONHE to optimise triage and timely management of patients in the ED.