Background: Visualization of the ocular fundus is critical part of the screening physical examination for selected patients in the ED. Our objective was to determine if non-mydriatic fundus photography taken by nurse practitioners (NPs) and interpreted by neuro-ophthalmologists is superior to direct ophthalmoscopy as performed by ED physicians.
Methods: Patients seen in a university hospital ED with a chief complaint of headache, acute focal neurologic dysfunction, or vision loss; or a triage diastolic blood pressure ≥120 mmHg were enrolled prospectively. Non-mydriatic photography of both eyes was obtained by NPs during their usual ED shift. Photographs were rated for quality and interpreted by two neuro-ophthalmologists within 24 hours. Findings relevant to ED care were defined as disc edema, disc pallor, intraocular hemorrhage, grade III/IV hypertensive retinopathy, retinal vascular emboli or occlusion. Performance and outcome of direct ophthalmoscopy by ED physicians (masked to the fundus photography results) was systematically recorded. Nurse practitioners and patients rated ease, comfort, and speed of non-mydriatic fundus photography on a 10-point Likert scale (10 best). Timing of visit and photography were recorded by automated systems.
Results: 350 patients were enrolled. 44 (13%) of the 350 patients had a finding relevant to ED care identified by a neuro-ophthalmologist on fundus photographs. ED physicians performed direct ophthalmoscopy on 48 (14%) of the 350 patients. Eleven of the 44 findings were known before patients presented to the ED and an additional six were identified by ED ophthalmologic consultation. The other 27 were identified solely by means of fundus photography (82% of the 33 not known prior to ED presentation). Eighty-three percent of the 350 patients had at least one eye with a high quality photograph while only 3% of patients had no photographs of diagnostic value. Mean ratings were ≥8.7 for all measures. Median length of ED stay was 7.5 hours (IQR:4.2-17.5). The median photography session lasted 1.9 minutes (IQR:1.3-2.9), typically accounting for less that 0.5% of the patient’s total ED visit.
Conclusion: Despite a relatively high rate of ocular fundus findings relevant to ED patient care, direct ophthalmoscopy was not systematically performed. This led to a high rate of missed relevant findings. Non-mydriatic fundus photography taken by NPs and interpreted by neuro-ophthalmologists is a feasible, potential alternative to direct ophthalmoscopy in the ED. It is performed well by non-physician staff, is well-received by staff and patients, requires a trivial amount of time to perform.
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