Feasibility of nonmydriatic ocular fundus photography in the emergency department: Phase I of the FOTO-ED study

Abstract

Objectives: Examination of the ocular fundus is imperative in many acute medical and neurologic conditions, but direct ophthalmoscopy by nonophthalmologists is underutilized, poorly performed, and difficult without pharmacologic pupillary dilation. The objective was to examine the feasibility of nonmydriatic fundus photography as a clinical alternative to direct ophthalmoscopy by emergency physicians (EPs).

Methods: Adult patients presenting to the emergency department (ED) with headache, acute focal neurologic deficit, diastolic blood pressure ≥ 120 mm Hg, or acute visual change had ocular fundus photographs taken by nurse practitioners using a nonmydriatic fundus camera. Photographs were reviewed by a neuroophthalmologist within 24 hours for findings relevant to acute ED patient care. Nurse practitioners and patients rated ease, comfort, and speed of nonmydriatic fundus photography on a 10-point Likert scale (10 best). Timing of visit and photography were recorded by automated electronic systems.

Results: A total of 350 patients were enrolled. There were 1,734 photographs taken during 230 nurse practitioner shifts. 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 (standard deviation [SD] ≤ 1.9) for all measures. The median photography session lasted 1.9 minutes (interquartile range [IQR] = 1.3 to 2.9 minutes), typically accounting for less that 0.5% of the patient's total ED visit.

Conclusions: Nonmydriatic fundus photography taken by nurse practitioners is a feasible alternative to direct ophthalmoscopy in the ED. It is performed well by nonphysician staff, is well-received by staff and patients, and requires a trivial amount of time to perform.

Conflict of interest statement

Disclosures: The authors have no conflicts of interest or disclosures to report.

© 2011 by the Society for Academic Emergency Medicine.

Figures

Figure 1

Obvious severe bilateral papilledema from intracranial hypertension. (Photographs taken using the non-mydriatic fundus camera used for the FOTO-ED study).

Figure 2

Pie chart showing the distribution of the 44 relevant findings observed among 350 patients. The photographs in each slice were taken during the study.

Figure 3

Comparison of the single field of view for conventional direct ophthalmoscopy (enlarged inset) and non-mydriatic fundus photography (large photo). The most commonly used conventional direct ophthalmoscope only shows part of the optic disc, and requires active exploration of the fundus by the examiner, whereas a photograph taken with a non-mydriatic fundus camera allows visualization of the entire posterior pole of the ocular fundus, including the optic nerve, the macula, and the major retinal vessels.