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Merritt Lecturer Nancy J. Newman Spreads the Gospel of Nonmydriatic Ocular Fundus Photography



NONMYDRIATIC FUNDUS photographs of emergency department patients complaining of headache. (A) Optic disc edema. (B) Normal ocular fundus photograph after a recent neurosurgical shunting procedure, reported by the emergency department physician as being helpful in the evaluation of the case because it was normal.

H. Houston Merritt Lecturer Nancy Newman, MD, FAAN, discusses the FOTO-ED study, which found that emergency department physicians were not doing back of the eye exams. She proposes that nonmydriatic ocular fundus photography would be an easier alternative for emergency department physicians and neurologists to detect abnormal findings indicative of neurologic conditions or disorders.

BOSTON—There are not too many people in this universe who can wax poetic about the use of nonmydriatic ocular fundus photography to a roomful of neurologists, but Nancy J. Newman, MD, FAAN, did just that in the H. Houston Merritt Lecture here at the AAN Annual Meeting in April.

Describing the study she and her colleagues published in the New England Journal of Medicine in 2011, she noted that of 350 emergency department cases involving patients meeting any one of four criteria, which would medically require a fundoscopic exam, only 44 actually received it.

“Only 14 percent,” she told a reporter a few days after her lecture. “And they detected absolutely zero percent of the relevant findings. The study was of ED physicians, but every neurologist in that hall was admitting to themselves that they don't use the ophthalmoscope that's in their own office. I feel like I've pulled away the curtain on an ugly truth: Nobody is using this thing. It's what we teach medical students, but it's a very difficult skill to learn, and even preceptors will tell them, ‘Don't bother with it.’”


DR. NANCY J. NEWMAN: “It is likely that within five years, youre going to walk up with your tablet or your phone, youll hold it up to the patient, tell them ‘Look here,’ and boom, youll have two beautiful views of the back of the eyes.”

Dr. Newman, professor of neurology and ophthalmology at Emory University School of Medicine, and the LeoDelle Jolley Professor of Ophthalmology, believes there is a technological solution to the problem of under-performed exams of the back of the eye.

“About ten years ago,” she said, “We noticed that the specialized cameras used in ophthalmology departments had improved to the point where you didn't even need to dilate the patient's pupils in order to get a good picture of the ocular fundus. They're still big and clumsy, and they cost between $15,000 and $25,000. But the price keeps dropping, and meanwhile smartphone cameras are getting better. It is likely that within five years, you're going to walk up with your tablet or your phone, you'll hold it up to the patient, tell them ‘Look here,’ and boom, you'll have two beautiful views of the back of the eyes.”

Nonmydriatic ocular fundus photography is not only easier but more accurate for physicians seeking to detect abnormal findings, Dr. Newman said, and she and her colleagues at Emory have reported as much in a series of papers published in JAMA Neurology, emergency medicine journals, and elsewhere.

She chose to make the eye her neurological sub-specialty, she said, because it is usually practiced in an academic setting, and she wanted to be not only a clinician but a researcher and teacher. What's more, she said, “Most neurology subspecialties are disease packages. You're dealing with movement disorders or strokes, for example. Whereas the visual system can capture every disease there is in neurology.”

When asked to give the biannual Merritt lecture, she said with a mischievous smile, “It was kind of cool that they didn't tell me what to speak on. They said, ‘What's the title of your talk?’ I thought about discussing our gene therapy study for Leber's hereditary optic neuropathy, because it's the first one of its kind. It's very exciting. We're still collecting data. But the neurologists don't see these patients when the diagnosis is correctly made, so I wasn't sure of the relevance for the AAN.”

Instead, she decided to focus her lecture on the fundoscopy study of ED physicians, known as the FOTO-ED study, a collaborative effort between her colleagues in Emory neuro-ophthalmology and the Emory emergency medicine department.

“It stands for “Fundus Photography vs. Ophthalmoscopy Trial Outcomes in the Emergency Department.”

The trial selected patients presenting with one of four complaints for which a fundoscopic evaluation is indicated: headache, focal neurologic deficit, diastolic blood pressure over 120, or visual complaints.

“You would think that somebody who has vision complaints would get the back of their eye examined,” she said with a sigh.

All of the patients who met the entry criteria underwent nonmydriatic ocular fundus photography, but in the first phase of the study, the ED physicians were not shown the photographs. In the second phase, the photographs were made immediately available to the physicians on the patients' electronic medical records. This time, 68 percent of the ED physicians looked at the photographs. That was a great improvement over the 14 percent who had examined the patients' eyes with an ophthalmoscope, and as a result, they correctly identified relevant findings 46 percent of the time. (A third phase, in which the physicians had to watch a 30-minute web-based video on how to properly interpret the photographs, did not increase their accuracy any further.)

Even so, Dr. Newman said, “We believe this kind of photography would be a huge help in neurology offices.”

With over 450 publications on her CV, Dr. Newman was the co-editor of Walsh & Hoyt's Clinical Neuro-Ophthalmology, fifth and sixth editions, and co-author of Neuro-Ophthalmology Illustrated, the second edition of which won the first place in the neurology category of the 2016 British Medical Association publishing awards.

Being asked to deliver the Merritt Lecture was actually one of two major awards for her in 2017. In May, she will deliver one of Emory University School of Medicine's highest awards, the Dean's Distinguished Faculty Lecture and Award for 2017. For that award, she will talk about her gene therapy work.

Her lecture at the AAN meeting was just the beginning of her lectures for the week; she was the director of four AAN courses later that week in Boston. She routinely lectures around the world, and was named the prestigious Hoyt Lecturer by the North American Neuro-Ophthalmology Society and the American Academy of Ophthalmology in 2013.

In addition to her research, teaching and clinical work, of course, she also has administrative duties. But, she said with a laugh, “No one likes to talk about administration. It's too boring.”


•. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic ocular fundus photography in the emergency department N Engl J Med 2011; 364 (4): 387–389.
•. Bruce BB, Biousse V, Newman NJ. Nonmydriatic ocular fundus photography in neurologic emergencies. Review article JAMA Neurol 2015; 72 (4): 455–499.
•. Thulasi P, Fraser CL, Biousse V, et al. Nonmydriatic ocular function among headache patients in an emergency department Neurology 2013: 80(5):432–437.