Shunt failure in children: Is papilloedema a reliable indicator?

Ventriculo-peritoneal shunt (VPS) placement is a common neurosurgical procedure for hydrocephalous. VPS failure rates have been estimated at approximately 11%-25% within the first year especially in pediatric patients. Patients with shunt failure due to obstruction may present with headache, lethargy, nausea, vomiting, vision loss, and Papilloedema. A 7-year-old boy with Dandy Walker syndrome post VPS presented with complains of headache and progressive loss of vision for the past 10 days. Vision BE - 3/60. Fundus examination revealed normal fundus and no papilloedema. Computed tomography scan showed shunt tube was in-situ with arachnoid cyst. Lumbar puncture analysis was normal. Visual Evoked Potential showed prolonged P100 latency so a trial of Intravenous Methylprednisolone was given. But patient did not improve and there was deterioration of vision further to BE - PL + PR +. So exploration of VPS was made and found to be malfunctioning. Shunt revision was done. Two months after the procedure, vision in RE improved to 6/60 and LE HM. BE fundus showed pallor of the disc. Increased Intracranial Pressure after shunt failure can present without papilloedema. High index of suspicion for shunt failure should be there in cases presenting with other symptoms and signs of increased Intracranial Pressure even in the absence of papilloedema. Early diagnosis is very crucial to prevent visual morbidity and also mortality.