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Author Notes:

Correspondence: Dr. Nancy J. Newman, Neuro-Ophthalmology Unit, Emory Eye Center, 1365-B Clifton Rd. NE, Atlanta, GA 30322; Phone: (404) 778-5360; Fax: (404) 778-4849; Email: ophtnjn@emory.edu

Author contributions: BBB, DWW, NJN, and VB conceived and designed the study.

BBB, DWW, and VB obtained research funding.

BBB, MTK, AW, KLH, DWW, NJN, and VB supervised the conduct of the trial and data collection.

BBB, PT, CLF, and AW collected and managed data.

BBB performed statistical analysis.

BBB drafted the article, and all authors approved it after contributing substantially to its revision.

BBB takes responsibility for the paper as a whole.

Acknowledgments: Supervising editor: Allan B. Wolfson, MD

Disclosures: None of the authors have any conflict of interest.


Research Funding:

Dr. Bruce receives research support from NIH/NEI (K23-EY019341), received research support from the NIH/PHS (KL2-RR025009, UL1-RR025008) and the Knights Templar Eye Foundation; and received the American Academy of Neurology Practice Research Fellowship. Dr. Thulasi has no disclosures. Dr. Fraser received the RANZCO Eye Foundation Scholarship and the Sydney Eye Alumni Travelling Fellowship Grant. Nurse Ward has no disclosures. Dr. Heilpern has no disclosures. Dr. Wright received research support from NIH/PHS (KL2-RR025009). Dr. Biousse received research support from NIH/PHS (UL1-RR025008). Dr. Newman is a recipient of the Research to Prevent Blindness Lew R. Wasserman Merit Award. Dr. Newman has provided expert testimony on the topic of papilledema.

Diagnostic accuracy and use of non-mydriatic ocular fundus photography by emergency department physicians: Phase II of the FOTO-ED study


Journal Title:

Annals of Emergency Medicine


Volume 62, Number 1


, Pages 28-33.e1

Type of Work:

Article | Post-print: After Peer Review


Objective During the first phase of the FOTO-ED Study, 13% (44/350;95%CI:9–17%) of patients had an ocular fundus finding, such as papilledema, relevant to their emergency department (ED) management found by non-mydriatic ocular fundus photography reviewed by neuro-opthalmologists. All of these findings were missed by ED physicians (EPs), who only examined 14% of enrolled patients by direct ophthalmoscopy. In the present study, we evaluated the sensitivity of non-mydriatic ocular fundus photography, an alternative to direct ophthalmoscopy, for relevant findings when photographs were made available for use by EPs during routine clinical care. Methods 354 patients presenting to our ED with headache, focal neurologic deficit, visual change, or diastolic blood pressure ≥120 mmHg had non-mydriatic fundus photography obtained (Kowa nonmyd-alpha-D). Photographs were placed on the electronic medical record for EPs review. Identification of relevant findings on photographs by EPs was compared to a reference standard of neuro-ophthalmologist review. Results EPs reviewed photographs of 239 patients (68%). 35 patients (10%;95%CI:7–13%) had relevant findings identified by neuro-ophthalmologist review (6 disc edema, 6 grade III/IV hypertensive retinopathy, 7 isolated hemorrhages, 15 optic disc pallor, and 1 retinal vascular occlusion). EPs identified 16/35 relevant findings (sensitivity:46%;95%CI:29–63%), and also identified 289/319 normal findings (specificity:96%; 95%CI:87–94%). EPs reported that photographs were helpful for 125 patients (35%). Conclusions EPs used non-mydriatic fundus photographs more frequently than they perform direct ophthalmoscopy, and their detection of relevant abnormalities improved. Ocular fundus photography often assisted ED care even when normal. Non-mydriatic ocular fundus photography offers a promising alternative to direct ophthalmoscopy.

Copyright information:

© 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommerical-NoDerivs 3.0 Unported License (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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