Nonmydriatic ocular fundus photography among headache patients in an emergency department

Abstract

Objectives: Determine the frequency of and the predictive factors for abnormal ocular fundus findings among emergency department (ED) headache patients.Methods: Cross-sectional study of prospectively enrolled adult patients presenting to our ED with a chief complaint of headache. Ocular fundus photographs were obtained using a nonmydriatic fundus camera that does not require pupillary dilation. Demographic and neuroimaging information was collected. Photographs were reviewed independently by 2 neuroophthalmologists for findings relevant to acute care. The results were analyzed using univariate statistics and logistic regression modeling. Results:We included 497 patients (median age: 40 years, 73% women), among whom 42 (8.5%, 95% confidence interval: 6%-11%) had ocular fundus abnormalities. Of these 42 patients, 12 had disc edema, 9 had optic nerve pallor, 6 had grade III/IV hypertensive retinopathy, and 15 had isolated retinal hemorrhages. Body mass index $35 kg/m 2 (odds ratio [OR]: 2.3, p 5 0.02), younger age (OR: 0.7 per 10-year increase, p 5 0.02), and higher mean arterial blood pressure (OR: 1.3 per 10-mm Hg increase, p 5 0.003) were predictive of abnormal retinal photography. Patients with an abnormal fundus had a higher percentage of hospital admission (21% vs 10%, p 5 0.04). Among the 34 patients with abnormal ocular fundi who had brain imaging, 14 (41%) had normal imaging.Conclusions: Ocular fundus abnormalities were found in 8.5% of patients with headache presenting to our ED. Predictors of abnormal funduscopic findings included higher body mass index, younger age, and higher blood pressure. Our study confirms the importance of funduscopic examination in patients with headache, particularly in the ED, and reaffirms the utility of nonmydriatic fundus photography in this setting. In the emergency department (ED), headache is the fourth most common chief complaint among all patients and the single most common neurologic chief complaint.1 More than 3 million ED visits for headache occurred in the United States during 2008, 2 and it is estimated that 3% to 5% of the general population has visited an ED for headache.3 The vast majority of these headaches are primary, requiring only symptomatic relief. 2,4,5 However, approximately 2% of all patients with headache and more than 18% of patients with sudden, severe headaches have a serious underlying cause. 4,[6][7][8][9] The frequency of secondary headaches also increases with age, occurring in almost 15% of headache sufferers older than 75 years. 4 The ED physician has the difficult task of discriminating between nonemergent headaches and those requiring acute care. Examination of the ocular fundus is one aspect of the physical examination that helps screen for potential "red flags," such as papilledema, that suggest a more ominous cause of headache.10,11 Unfortunately, funduscopy, performed infrequently in acute care settings such as the ED, is also not accurately interpreted by nonophthalmology personnel. 10 Our goal was to

Overdiagnosis of idiopathic intracranial hypertension

“…In our study, 20% of care providers consulted for headaches did not attempt to perform ophthalmoscopy, while 44% of those who examined the ocular fundus misinterpreted the optic nerve appearance as papilledema. These numbers are consistent with the results of the FOTO-ED I study, 5,6 in which ED providers only performed ophthalmoscopy in 12% of patients presenting to an ED with a chief complaint of headaches, and also misinterpreted the ophthalmoscopy findings. Additionally, only 19% (15/79) of patients referred to us for evaluation of possible IIH (group II) were eventually diagnosed with IIH, emphasizing the difficulty for most physicians (including some neurologists and ophthalmologists in our study) to definitely diagnose or rule out IIH.…”

“…The study was approved by our institutional review board. 5,6 Using our appointment logs, we retrospectively reviewed all new patient encounters between November 2013 and June 2014 in one neuro-ophthalmology service of a tertiary center. We systematically reviewed all consultation letters and medical records for all new patients seen during the study period.…”

The demise of direct ophthalmoscopy

“…Patients from the Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study were the subject of a recent study in which ocular fundus photographs were used to determine the rate and predictors of abnormal ocular fundus findings among patients with headache in an emergency department setting. 8 Of the 497 patients in the study with headache, 42 (8.5%) had relevant ocular fundus abnormalities, including isolated retinal hemorrhages, optic disc edema, grade III or IV hypertensive retinopathy, and optic disc pallor. Importantly, many of the patients with ocular fundus abnormalities had unremarkable physical examinations and 41% had normal neuroimaging studies, reinforcing the critical role of ocular funduscopy in patients with headache.…”

The essential neurological examination of the unconscious patient in the emergency room

“…Moreover, technical difficulties and time consumption of the examination itself, time‐consuming examination, and an overall low sensitivity for detecting papilledema in undilated pupils by nonophthalmologists may also play important roles. The availability of new devices, like nonmydriatic cameras (Thulasi, Fraser, Biousse, Wright, Newman & Bruce, 2013), may be a way to overcome the technical barriers, but more data are needed about the diagnostic value in this specific patient population.…”