Nonmydriatic Ocular Fundus Photography in the Emergency Department

Abstract

T h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 364;4 nejm.org january 27, 2011 388 one inclusion criterion. Trained nurse practitioners obtained ocular fundus photographs (Fig. 1) with a nonmydriatic fundus camera (Kowa α-D). Photographs were reviewed by a neuro-ophthal-mologist within 24 hours for findings relevant to treatment in the emergency department. The performance of emergency department physicians and the findings on direct ophthalmoscopy were prospectively recorded, with the physicians unaware of the photography results. During routine evaluation, ophthalmoscopy was performed by an emergency department physician for only 48 of the 350 patients (14%; 95% confidence interval [CI], 10 to 18). In 44 enrolled patients, relevant ocular findings (13%; 95% CI, 9 to 17) were identified with the use of nonmyd-riatic fundus photography: 13 cases of optic-nerve edema, 13 intraocular hemorrhages, 10 instances of hypertensive retinopathy (grade 3 or 4), 4 cases of arterial vascular occlusion, and 4 instances of optic-nerve pallor (for details see the table in the Supplementary Appendix, available with the full text of this letter at NEJM.org). Eleven of the findings were known before patients presented to the emergency department. Of the remaining 33 relevant findings, 6 were identified on ophthalmo-logic consultation to the emergency department and 27 solely by means of fundus photography (82%; 95% CI, 65 to 93). (In only 5 of these 33 patients was ophthalmoscopy performed by an emergency department physician; results were recorded as normal for all 5 patients.) The photographs were of diagnostic value for 97% of enrolled patients. Median photography time was 1.9 minutes (interquartile range, 1.3 to 2.9). Ophthalmoscopy was performed infrequently and poorly by emergency department physicians. We observed that 13% of patients presenting to the emergency department at a large academic center with symptoms or conditions warranting ocular fundus examination had a finding that was relevant to the systemic and ophthalmic management and disposition of their case by the department. Nonmydriatic fundus photography easily detected relevant ocular fundus findings that were otherwise overlooked, and the photography was performed efficiently by nonphysician staff.. Panel A, which shows a normal posterior pole, is an example of the normal field of view in nonmydriatic fundus photography, which includes the optic nerve, macula, and major retinal vessels. The inset shows the single field of view typical of the most commonly used conventional direct ophthalmo-scopes, which reveals only part of the optic-nerve head and requires active exploration of the fundus by the examiner. Panel B shows an intraocular hemorrhage and Panel C grade IV hypertensive retinopathy, with optic-nerve edema, arterial attenuation, and retinal hemorrhages. Panel D shows optic-nerve edema from intracranial hypertension, Panel E acute retinal is-chemia from central retinal-artery occlusion, and Panel F optic-nerve pallor. The black backgrounds of the original images were cropped, and the brightness and contrast were adjusted. The New England Journal of Medicine Downloaded from nejm.org on January 14, 2024. For personal use only. No other uses without permission.