Paton lines are curved retinal folds around a swollen optic disc, classically seen in papilledema.
Leslie Paton and Gordon Holmes described them in their 1911 histological study of papilledema.
Today, OCT shows them far more clearly than the ophthalmoscope.
Recognizing them helps confirm true disc edema and judge its severity.
What Paton Lines Look Like
On fundus examination, Paton lines appear as fine, curved, parallel striations next to the disc margin.
They run circumferentially and follow the contour of the swollen nerve head.
The temporal side usually shows them best.
In addition, red-free light makes them easier to see.
Why the Folds Form
Axoplasmic stasis swells the nerve fiber layer at the disc.
As a result, the expanding nerve head pushes the adjacent retina outward.
The peripapillary retina has little room to move, so it buckles into folds.
Raised pressure in the nerve sheath may also deform the peripapillary Bruch membrane and add mechanical stress.
Fundus Explorer Pro
Photograph the retinal findings described here with the phone already in your pocket — 22 D optics and built-in illumination in one handheld unit.
From Choroida — the team behind this sitePaton Lines on OCT
OCT B-scans through the disc margin show the folds as undulations of the retinal layers.
In many eyes, the wrinkling involves the inner retina and the outer nuclear layer.
Meanwhile, the retinal pigment epithelium under these folds usually stays smooth.
Therefore, OCT helps separate them from folds that start in the choroid.
The IIHTT OCT Substudy
Sibony and colleagues analyzed folds in patients from the Idiopathic Intracranial Hypertension Treatment Trial.
They described peripapillary wrinkles, retinal folds and choroidal folds as separate patterns.
OCT detected folds that fundus photographs often missed.
Folds also tended to accompany more severe disc swelling.
Paton Lines vs Choroidal Folds
Choroidal folds involve the choroid, Bruch membrane and RPE.
Clinically, they appear as broader alternating light and dark bands.
They often cross the posterior pole horizontally or obliquely (see choroidal folds).
Paton lines, by contrast, stay close to the disc and follow its edge.
Imaging Clues That Separate Them
Fluorescein angiography shows choroidal folds as alternating hyperfluorescent and hypofluorescent stripes.
Paton lines lack this pattern, because the RPE remains flat.
On OCT, choroidal folds show a wavy RPE and Bruch line over an undulating choroid.
Enhanced depth imaging also makes the choroidal contour easier to judge.
Can Both Appear Together?
Both fold types can coexist in papilledema.
In this setting, choroidal folds may reflect pressure transmitted to the posterior globe.
However, choroidal folds also occur in hyperopia, orbital masses, scleritis and hypotony.
Therefore, their presence alone does not prove raised intracranial pressure.
What Paton Lines Tell You About Disc Swelling
These folds point to genuine edema of the nerve head.
For example, they help separate swollen discs from pseudopapilledema, where such folds are not expected.
Buried drusen and crowded discs usually lack them (see optic disc drusen).
However, their absence does not exclude papilledema.
Paton Lines in Other Disc Edema
These folds are not specific to raised intracranial pressure.
They may appear with any marked disc swelling, including ischemic optic neuropathy and optic neuritis.
Therefore, they confirm swelling, while the cause still needs its own workup.
A structured approach to disc edema helps (see optic disc swelling causes).
Symptoms and Paton Lines
Most patients have no symptoms from the folds themselves.
Vision in papilledema usually depends on optic nerve function.
However, folds that extend toward the fovea may cause metamorphopsia or blur.
Then, macular OCT clarifies whether folds or fluid explain the complaint.
Examining for Paton Lines
First, examine the disc stereoscopically at the slit lamp with a high plus lens.
Next, use red-free light and inspect the temporal margin.
Then, obtain OCT line scans perpendicular to the disc edge.
Finally, take fundus photographs for later comparison.
Paton Lines at Follow-Up
Folds tend to fade as disc swelling resolves.
As a result, serial OCT can track the response to treatment of the underlying cause.
Some folds may persist for a while after the disc settles.
Therefore, interpret a residual fold alongside RNFL thickness and visual function.
Talking to the Patient
Explain that the lines are wrinkles in the retina caused by nerve swelling.
They rarely harm vision by themselves.
In addition, stress that the cause of the swelling matters most.
Timely workup and repeat imaging therefore stay essential.
Pitfalls to Avoid
- Calling every peripapillary fold a choroidal fold
- Absent folds do not prove pseudopapilledema
- Folds do not always mean raised intracranial pressure
- Skipping OCT when the fundus view is unclear
- Forgetting a macular scan when vision drops
For the latest studies, see the PubMed results for paton lines.
Document what you see
Two smartphone imaging tools built for everyday clinic use — one for the slit lamp, one for the fundus.
From Choroida — the team behind this siteReferences
- Paton L, Holmes G. The pathology of papilloedema: a histological study of sixty eyes. Brain. 1911;33:389-432.
- Sibony PA, Kupersmith MJ, Feldon SE, et al. Retinal and choroidal folds in papilledema. Invest Ophthalmol Vis Sci. 2015;56:5670-5680.
- Sibony P, Kupersmith MJ, Rohlf FJ. Shape analysis of the peripapillary RPE layer in papilledema and ischemic optic neuropathy. Invest Ophthalmol Vis Sci. 2011;52:7987-7995.
- Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology. 2013;81:1159-1165.
- American Academy of Ophthalmology. Basic and Clinical Science Course, Section 5: Neuro-Ophthalmology. San Francisco: AAO; 2023.
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