Feasibility of Nonmydriatic Ocular Fundus Photography in the Emergency Department: Phase I of the FOTO-ED Study

Authors

  • Beau B. Bruce MD, MS,

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • Cédric Lamirel MD,

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • Valérie Biousse MD,

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • Antionette Ward NP,

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • Katherine L. Heilpern MD,

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • Nancy J. Newman MD,

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • David W. Wright MD

    1. From the Departments of Ophthalmology (BBB, CL, VB, NJN), Neurology (BBB, VB, NJN), Neurological Surgery (NJN), and Emergency Medicine (DWW, AW, KLH), Emory University, Atlanta, GA.
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  • Presented at the North American Neuro-ophthalmology Society meeting, Tuscon, AZ, March 2010; the American Academy of Neurology annual meeting, Toronto, Ontario, Canada, April 2010; the Association for Research in Vision and Ophthalmology annual meeting, Ft. Lauderdale, FL, May 2010; and the American Academy of Ophthalmology annual meeting, Chicago, IL, October 2010.

  • This study was supported in part by a departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York, by core grant P30-EY06360 (Department of Ophthalmology). Dr. Bruce has received research support from NIH/NCRR (KL2-RR025009, UL1-RR025008), the NIH/NEI (K23-EY019341), and Knights Templar Eye Foundation and received the American Academy of Neurology Practice Research Fellowship. Dr. Lamirel receives research support from Institut Servier (Paris, France), Fondation Planiol (Varennes, France), Ophthalmologie Progrès en Anjou (Angers, France), and the Philippe Foundation, Inc. (New York, NY). Dr. Wright received research support from NIH/PHS (KL2-RR025009). Dr. Biousse received research support from NIH/PHS (UL1-RR025008) and the Knights Templar Eye Foundation. Dr. Newman is a recipient of the Research to Prevent Blindness Lew R. Wasserman Merit Award.

  • The authors have no relevant financial information or potential conflicts of interest to disclose.

  • Supervising Editor: Jacob Ufberg, MD.

Address for correspondence and reprints: Beau B. Bruce, MD, MS; e-mail: bbbruce@emory.edu.

Abstract

ACADEMIC EMERGENCY MEDICINE 2011; 18:928–933 © 2011 by the Society for Academic Emergency Medicine

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.

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