Optic Nerve Head Edema (ONHE) Among Patients Presenting to the Emergency Department In The FOTO-ED Study (Fundus photography vs. Ophthalmoscopy Trial Outcomes in the Emergency Department)

Abstract

Purpose : The FOTO-ED study showed that non-mydriatic retinal photography in the emergency department (ED) is feasible and may improve patient care and outcomes when systematically performed in patients with a chief complaint of headache, neurologic deficit, visual loss, or elevated blood pressure (BP). Finding ONHE is particularly important in this patient population. The purpose of this study was to describe the characteristics of the patients diagnosed with ONHE in FOTO-ED phases 1-3 and test the hypothesis that presence of disc edema alters the management of the patients presenting to ED.

Methods : Cross-sectional analysis of patients diagnosed with ONHE in all 3 phases of the prospective FOTO-ED study. The ONHE subgroup was compared to the non-ONHE group using logistic regression.

Results :
The FOTO-ED studies included 1429 patients, among whom 36 (2.5%, 95% CI:1.8-3.5%) had ONHE [median age, 31 (IQR:27-40), women, 71.4%, African-Americans, 77.8%]. ONHE was bilateral in 26/36 and unilateral in 10/36 patients. Chief complaints included headaches (18/36), acute visual deficit (10/36), acute neurological deficit (4/36), elevated BP (2/36), both headaches and acute visual deficit (2/36). Final diagnoses were IIH (18/36), optic neuritis (3/36), CSF shunt malfunction/infection (3/36); 2 each with brain tumor, non-arteritic ischemic optic neuropathy, cerebral venous sinus thrombosis, and malignant hypertension; and 1 each with meningitis, cerebral infarction, neurosarcoidosis, and retinopathy. 15/36 patients were sent to the ED with a diagnosis of ONHE already made by the referring physician; fundus photographs were the first to establish ONHE in 21/36 (58%) while in the ED; the ED providers identified the presence of ONHE in only 5/21 (23.8%) of these patients. Knowledge of ONHE led to a change in final diagnosis for 10/36 patients.

Conclusions : One in 40 patients (2.5%) presenting to the ED with a chief complaint of headache, neurologic deficit, visual loss, or elevated BP had ONHE. Our results are consistent with the hypothesis that the identification of ONHE altered the patient disposition and contributed to the final diagnosis, confirming the importance of funduscopic examination in the ED.

This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.