Biousse 2017
Biousse 2017
0000000000004868
VIEWS & REVIEWS
®
Dr. Newman
Neurology 2018;90:1-9. doi:10.1212/WNL.0000000000004868 [email protected]
Abstract
Although the usefulness of viewing the ocular fundus is well-recognized, ophthalmoscopy is
infrequently and poorly performed by most nonophthalmologist physicians, including neu-
rologists. Barriers to the practice of ophthalmoscopy by nonophthalmologists include not only
the technical difficulty related to direct ophthalmoscopy, but also lack of adequate training and
discouragement by preceptors. Recent studies have shown that digital retinal fundus photo-
graphs with electronic transmission and remote interpretation of images by an ophthalmologist
are an efficient and reliable way to allow examination of the ocular fundus in patients with
systemic disorders such as diabetes mellitus. Ocular fundus photographs obtained without
pharmacologic dilation of the pupil using nonmydriatic fundus cameras could be of great value
in emergency departments (EDs) and neurologic settings. The Fundus Photography vs
Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study showed
that ED providers consistently failed to correctly identify relevant ocular funduscopic findings
using the direct ophthalmoscope, and that nonmydriatic fundus photography was an effective
alternate way of providing access to the ocular fundus in the ED. Extrapolating these results to
headache clinics, outpatient neurology clinics, and adult and pediatric primary care settings
seems self-evident. As technology advances, nonmydriatic ocular fundus imaging systems will
be of higher quality and more portable and affordable, thereby circumventing the need to
master the use of the ophthalmoscope. Visualizing the ocular fundus is more important than the
method used. Ocular fundus photography facilitates nonophthalmologists’ performance of this
essential part of the physical examination, thus helping to reestablish the value of doing so.
From the Departments of Ophthalmology (V.B., B.B.B., N.J.N.), Neurology (V.B., B.B.B., N.J.N.), Epidemiology (B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of
Medicine, Atlanta, GA.
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Case history 1 diversion, her vision improves only slightly and she remains
legally blind.
A 28-year-old woman presents to an emergency department
(ED) with severe headache, neck pain, and nausea. Her ex-
amination is recorded as normal; she is diagnosed with mi- Case history 2
graine headaches, treated with analgesics, and sent home.
Two weeks later, she returns to the same ED complaining of A 20-year-old woman goes to an ED with severe headache,
continued headaches and new blurred vision in both eyes. neck pain, and nausea. Her chief complaint of headache
Examination is again recorded as normal and a CT scan of triggers the acquisition of ocular fundus photographs on
the head without contrast is unremarkable. She is diagnosed a nonmydriatic fundus camera in the ED as part of a research
again with migraine, and sent home with an outpatient study on the feasibility and usefulness of fundus photographs
neurology referral. A week later, she is seen in an outpatient during routine ED care (figure 2). The photographs are
neurology clinic, where an electronic medical record indi- uploaded into the electronic medical record where they are
cates a normal neurologic examination, including normal viewed by the ED provider and recognized as showing pap-
cranial nerves, and she is referred for outpatient ophthal- illedema. This is confirmed by telemedical assessment of the
mologic evaluation. By the time she sees the ophthalmolo- photographs remotely by an ophthalmologist. The patient’s
gist the following week, her vision is recorded as no workup occurs immediately in the ED and neuro-
perception of light in the right eye and perception of light ophthalmologic evaluation confirms the diagnosis of IIH
only in the left eye, with bilateral severe papilledema on and the need for immediate neurosurgical management. The
ocular funduscopic examination (figure 1). She is sent patient maintains excellent central visual acuity with mild
emergently to the ED, where a brain MRI and magnetic peripheral visual field deficits, none of which remains symp-
resonance venography are normal with the exception of ra- tomatic or functionally limiting.
diographic signs of elevated intracranial pressure1 and
a lumbar puncture confirms an elevated opening pressure of
>55 cm H2O with otherwise normal CSF contents, estab-
Scope of the problem
lishing the diagnosis of idiopathic intracranial hypertension In 1851, by the light of a candle, Hermann von Helmholtz
(IIH).2,3 Despite immediate surgical intervention for CSF viewed the living human ocular fundus via direct
Barriers to adequate performance of Although most smartphone photography to date does not
provide high-quality nonmydriatic retinal imaging, expected
the ocular funduscopic examination technical improvements will soon likely allow these cameras
Performing direct ophthalmoscopy is not easy. Ocular fundus to replace the outdated direct ophthalmoscope in the pocket
examination is listed second in the Stanford Medicine 25 list of any medical care provider.
that photographs were available by an eye icon appearing on findings on ocular fundus photographs. Trained ED providers
the list of tests performed for each patient. There was no reviewed 45% of photographs and correctly identified ab-
incentive to encourage the ED providers to open the pho- normal images in 67% of cases and normal images in 80% of
tography folder and the ED providers did not receive any cases before training, compared with 43%, 45%, and 83%,
specific education regarding how to interpret fundus photo- respectively, after training. Untrained ED providers reviewed
graphs. Of the 354 enrolled patients in phase II, 35 (10%; 95% 35% of photographs and correctly identified abnormal find-
CI 7%–13%) had relevant findings identified on the fundus ings in 50% of cases and normal images in 79% of normal
photographs by a neuro-ophthalmologist. The ED providers cases. This study confirmed that ED providers perform much
reviewed the photographs in 239 patients (68%), which was better with fundus photography than with direct ophthal-
much higher than their 14% frequency of examination of the moscopy, especially to identify normal fundus photographs.
ocular fundus with the direct ophthalmoscopy in phase I. However, the in-service training did not result in significant
Importantly, they identified relevant abnormalities in 16 of 35 improvement in the interpretation of these photographs.
patients (sensitivity 46%; 95% CI 29%–63%), which was also
much better than the 0% detection rate with only the direct The 3 phases of the FOTO-ED study clearly showed that
ophthalmoscope in phase I. The ED providers also correctly most ED providers consistently fail to correctly identify rel-
identified 289 of 319 ocular fundus photographs as normal evant ocular funduscopic findings using the direct ophthal-
(specificity 96%; 95% CI 87%–94%), which they believed was moscope, and that nonmydriatic fundus photography is an
particularly helpful (e.g., allowing exclusion of papilledema in effective alternate way of providing access to the ocular fundus
a patient with headaches). in the ED. A total of 1,291 patients were included in the 3
phases of the FOTO-ED study, among whom 153 (12%) had
The third phase of the FOTO-ED study was a quality im- relevant findings on fundus photographs that altered the ED
provement project performed to determine whether a 30- management of these patients. The ED providers were not
minute web-based educational module would improve the ED able to identify any of the relevant findings in phase I without
providers’ performance.47 Consistent with previous phases of the help of an ophthalmologist consultant, but they recog-
the FOTO-ED study, 12.6% (74) of the 587 patients pre- nized 40 of the 109 (36.7%) relevant findings when given
senting to the ED with eligible chief complaints had relevant access to fundus photographs in phases II and III. They also
ED physician fundus examination technique Direct ophthalmoscopy Nonmydriatic photography Nonmydriatic photography
Patients whose ocular fundus was viewed by ED 48 (14) 239 (68) 237 (40)
physicians, n (%)
correctly identified 448 out of the 515 (87%) normal images, The applications of this technology in neurology settings are
which was believed to be very helpful, particularly in patients multiple and go beyond the assessment of papilledema in
with headaches in whom papilledema could be easily and headache patients. For example, recognition of grade III/IV
reliably excluded. hypertensive retinopathy is important in numerous neuro-
logic emergencies.43,53,54 Ocular fundus photography may also
Future applications prove useful in the risk stratification of patients presenting
with suspected TIA or stroke48,55–57 or in critically ill patients
The FOTO-ED study triggered a great deal of interest and in whom identification of ocular fundus abnormalities may
enthusiasm not only from ED providers, but medical students, affect acute management and prognosis.58
residents, and nonophthalmology physicians such as neurol-
ogists. Indeed, the findings of the FOTO-ED study can likely New inexpensive, portable, easy-to-operate fundus cameras
be extrapolated to other nonophthalmologic settings.48,49 have revolutionized retinal screening programs, which have
Numerous other studies have now validated the use of cam- grown exponentially over the last decade. Tele-
eras in clinical settings other than adult EDs.50–54 The feasi- ophthalmology screening is now the standard of care in
bility and reliability of nonmydriatic fundus photography in linking remote areas to ophthalmologists.41 Neurology clinics,
children as young as 22 months was demonstrated in a pedi- primary care offices, urgent care centers, and EDs can use any
atric ophthalmology clinic.50 A subsequent study validated the of the nonmydriatic cameras that connect directly to elec-
use of a tabletop nonmydriatic camera in children ages 5–12 tronic medical records and integrate fundus photographs into
years in a pediatric ED.51 Another study showed that relatively a patient’s systematic evaluation. Although the hope is that
good images of the optic disc could be obtained in children as most physicians will learn to accurately interpret the photo-
young as 2 years without pupillary dilation using a smart- graphs themselves, remote interpretation by an ophthalmol-
phone attached to an ophthalmoscope.52 ogist is always possible, facilitated by the integrated Internet