One side of a phone consultation overheard in a community emergency department:
Well, the patient isn't dilated, so I didn't get a great look. And he is photophobic and quite squirrelly.
Cup-to-disc ratio? Not sure. Can you remind me what's normal?
No, I don't think there is papilledema.
I think perhaps you should have a look.
Yes, it would be great if I could flick a photo your way. Tele-eyeball. Maybe someday.
OK, see you in a couple of hours. I'll have him dilated by then.
As we know, direct ophthalmoscopy is challenging, even in the most skilled hands. Even ophthalmologists miss about half of the relevant fundus findings with direct ophthalmoscopy compared with the indirect technique. (Acta Ophthalmol. 2012;90:503, http://bit.ly/2CP4TG8; Neurol Clin Pract. 2015;5:150, http://bit.ly/2OtCbQD.) We think it's fair to posit that most EPs and ophthalmologists would welcome an alternate means of fundus evaluation in patients presenting with acute complaints, including headache and visual changes.
It turns out that there is another option, but it probably hasn't disseminated to your ED just yet. It's called nonmydriatic ocular fundus photography, and it offers an alternative to direct ophthalmoscopy via wide-field (45°) photographs of the ocular fundus to be taken without pharmacologic pupillary dilation. Maybe tele-eyeball is feasible, and there may be an effective way to share the fundus amongus.
The primary supporting literature is eight years old and restricted to adults, but a 2018 study seems to extend the feasibility to ages 5-12. (Pediat Emerg Care. 2018;34:488.) Let's start with the seminal FOTO-ED study, which looked at adults in the Emory University ED with fundus visualization complaints—headache, visual change, hypertensive urgency, and focal neurologic deficit. (New Engl J Med. 2011;364:387; http://bit.ly/2KqUswJ.) EPs provided standard care in phase I while research staff took nondilated digital fundus photos that were read by neuro-ophthalmologists within 24 hours. They found that there were quite a few meaningful (e.g., optic nerve edema) fundal findings (33/350), of which the EPs found precisely zero and ophthalmologic consults found just six.
Many of the findings did not require immediate action, but this certainly was not optimal. EPs in phase II were given access to the photos in real time without additional training. Compared with the first phase in which they only examined 14 percent of the patients by direct ophthalmoscopy, they examined 239 of 354 (68%) patients in phase II, and reported that the images were helpful in 125 (35%) cases. The EPs were also better able to visualize pathology, and identified 16 of 35 relevant findings (46%, absolute difference: 46%; 95% CI: 29%-62%; p<0.001). (Ann Emerg Med. 2013;62:28; http://bit.ly/32SGgme.) In phase III, 587 EPs received online training to improve interpretation of fundus photography. This phase did not, however, show a significant diagnostic benefit compared with phase II. (Neuroophthalmology. 2018;42:269; http://bit.ly/2OhgCCE.)
The phase II results were impressive and speak to a diagnostic advancement, not to mention less squinting into the aperture of a direct ophthalmoscope, but the innovation has not been widely adopted. That might soon change because of a proliferation of cheaper and easier-to-use alternatives, a number of which use smartphones, but one review concluded that the Panoptic ophthalmoscope smartphone adapter, the Welch Allyn iExaminer Pro app, and the D-Eye 20-D were not easy enough to use to be recommended. (Neurology. 2018;90:897.) The best option, in their review, was a handheld fundus camera, which the authors noted was easy to use.
The evidence from the FOTO-ED study was not surprising. I (Dr. Dimmig) despise the direct ophthalmoscope, and know firsthand how difficult it is to view the fundus without dilation and indirect ophthalmoscopy. What is striking from the FOTO-ED study, is the severity of the missed diagnoses, including papilledema (n=13) and retinal artery occlusion (n=4), which have a high potential for poor long-term outcomes.
The convergence of digital technologies (including the ability to photograph the fundus through the nondilated pupil), the ease of viewing images in the ED, and being able to share images by telemedicine makes this technology an excellent ED option.
The cost of the camera might be a hurdle, but the price is dropping, and that will likely continue. Even at the high end—$15,000-$20,000—the investment will pay for itself in legal protection and the possibility of future telemedicine billing. I think we can all agree that a fundus picture would be worth 1000 words considering those painful phone consults with the eye doctor.
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Dr. Ballardis an emergency physician at San Rafael Kaiser, a chair of the KP CREST Network, and the medical director for Marin County Emergency Medical Services. He is also the creator of the Medically Clear podcast on iTunes. Read his past articles athttp://bit.ly/EMN-MedClear. Dr. Dimmighas been in private practice in Bend, OR, for 14 years, specializing in cataract and glaucoma surgeries and has been involved in ophthalmology in Guatemala and Ethiopia throughout his career.