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Beau B. Bruce, Praneetha Thulasi, Clare L. Fraser, Matthew T. Keadey, Antoinette Ward, Katherine L. Heilpern, David W. Wright, Nancy J. Newman, Valérie Biousse; Non-mydriatic Ocular Fundus Photography Read by Emergency Department (ED) Physicians: FOTO-ED Study. Invest. Ophthalmol. Vis. Sci. 2012;53(14):1312.
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In the first phase of the FOTO-ED Study, 12.6% of 350 ED patients with complaints or conditions warranting ocular fundus examination had findings, such as papilledema, that should have altered their management or disposition. Disturbingly, only 14% of these 350 patients had direct ophthalmoscopy performed, and nearly all of the relevant findings were missed and identified solely by fundus photography reviewed by neuro-ophthalmologists. Our aim was to compare non-mydriatic ocular fundus photography read by ED physicians to their direct ophthalmoscopy.
Patients presenting to our ED with headache, focal neurologic defect, visual change, or diastolic blood pressure ≥120 were prospectively enrolled. Fundus photography was performed by a nurse practitioner or medical student using a non-mydriatic fundus camera (Kowa nonmyd-alpha-D). ED physicians were notified that photographs were available on the electronic medical record, but were not required to review the photographs.
354 patients were included from among 473 assessed for eligibility (exclusions: 85 ineligible, 33 refused participation). Photographs of 239 (68%) were reviewed by ED physicians. 35 patients (10%) had relevant findings identified by neuro-ophthalmologist review (6 disc edema, 6 grade III/IV hypertensive retinopathy, 7 isolated hemorrhages, 15 optic disc pallor, and 1 retinal vascular occlusion). 16 of those 35 relevant findings (46%) were identified by the ED physicians, eight (24%) occurred in patients whose photographs were not reviewed by ED physicians, and the remaining were reviewed but recorded as "likely normal" or "normal". The ED physicians reported that the photographs were helpful for 125 patients (35%).
Non-mydriatic fundus photographs were used more frequently than direct ophthalmoscopy by ED physicians, and were more sensitive to relevant abnormalities. Ocular fundus photography was often helpful in ED patient evaluations, even when normal. We next plan to investigate whether training in the interpretation of fundus photographs improves ED physician performance and facilitates appropriate ED management.
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