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B. B. Bruce, C. Lamirel, D. W. Wright, A. Ward, N. J. Newman, V. Biousse; Non-Mydriatic Fundus Photography in the Diagnosis of Acute Neuro-Ophthalmic Disease in the Emergency Department (ED). Invest. Ophthalmol. Vis. Sci. 2010;51(13):1449.
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Visualization of the ocular fundus remains a critical part of the screening physical examination for numerous 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.
Interim analysis of 309/350 planned, prospectively enrolled, consecutive patients seen in a university hospital ED with a chief complaint of headache, acute focal neurologic dysfunction, diastolic blood pressure >120 mmHg, or vision loss. Non-mydriatic photography of both eyes was obtained by NPs during their usual ED shift in the triage area and interpreted by two neuro-ophthalmologists within 24 hours. Urgent findings were defined as disc edema, disc pallor, intraocular hemorrhage, retinal whitening, severe vascular retinopathy, retinal vascular emboli or occlusion. Performance and outcome of direct ophthalmoscopy by ED physicians (masked to the fundus photography results) was systematically recorded.
ED physicians performed direct ophthalmoscopy on 64/309 (21%) of enrolled patients. 42/200 (13%) of patients had an urgent finding identified by a neuro-ophthalmologist on fundus photographs. The ED physicians performed direct ophthalmoscopy on 12/42 (29%) of patients with urgent findings but only identified one of these urgent findings. An additional 15 (39%) of the urgent findings were identified by consultation with other services, but 26 (62%) were not identified during the course of routine ED care (and would have been undiagnosed in the absence of non-mydriatic fundus photography).
ED physicians do not use the direct ophthalmoscope systematically; when they do the visualize the fundus by direct ophthalmoscopy, they almost always miss relevant findings. Even with 24 hour availability of on-call ophthalmologists, over half of urgent findings are missed. Fundus photography taken by NPs and interpreted by neuro-ophthalmologists by a telemedical approach is superior for the detection of urgent neuro-ophthalmic diagnoses in the ED.
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