Ocular fundus examination is a critical part of the physical examination in patients with severely elevated blood pressure (BP), which is defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) as a BP exceeding 180/120 mm Hg. Indeed, the presence or absence of severe, grade III/IV hypertensive retinopathy helps differentiate hypertensive emergencies requiring intensive care from less severe hypertensive urgencies. As a secondary analysis in the Fundus photography versus Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study, we sought to explore potential risk factors, in particular BP, for the presence of ocular fundus abnormalities relevant to the care of emergency department (ED) patients. We found evidence of acute end-organ ocular damage at lower blood pressures than the JNC7 criteria.

Objective: Non-mydriatic fundus photography by non-ophthalmic trained personnel has recently been shown to be a potential alternative to direct ophthalmoscopy in the emergency department (ED). We evaluated the reliability of a novel quality rating scale and applied this scale to non-mydriatic fundus photographs taken during routine ED patient encounters to determine factors associated with diminished photograph quality. Design: Prospective, cross-sectional Participants: 350 patients enrolled in the Fundus photography vs. Ophthalmoscopy Trials Outcomes in the Emergency Department (FOTO-ED) study were photographed by nurse practitioners after <30 minutes of training followed by supervision. Methods: Photographs of both eyes were graded for quality on two occasions by two neuro-ophthalmologists. Four regions were independently evaluated for quality: optic disc, macula, superior and inferior vascular arcades. Quality as a function of the number of photographs taken was evaluated by Kaplan-Meier analysis. Mixed effects ordinal logistic regression was used to evaluate for predictors of image quality while accounting for the repeated measures design. Main Outcome Measure: Overall photographic quality (1–5 scale, 5 best). Results: We evaluated 1734 photographs. Inter- and intra-observer agreements between neuro-ophthalmologists were very good (weighted kappa:0.84–0.87). Quality of the optic disc area was better than those of other retinal areas (p<0.002). Kaplan-Meier analysis showed that if a high-quality photograph of an eye was not obtained by the third attempt it was unlikely that one would be obtained at all. A 10 second increase in the inter-photograph interval before a total of forty seconds increased the odds of a one unit higher quality rating by 1.81 times (95%CI: 1.68–1.98), and a ten year increase in age decreased the odds by 0.76 times (95%CI: 0.69–0.85). Black patients had 0.42 times (95%CI: 0.28–0.63) the odds of a one unit higher quality rating compared to whites. Conclusions: Our 5-point scale is a reliable measure of non-mydriatic photograph quality. The region of interest, interphotograph interval, age, and race are significant predictors of image quality for non-mydriatic photographs taken by nurse practitioners in the ED. Addressing these factors may have a direct impact on the successful implementation of non-mydriatic fundus photography into the ED.

Examination of the ocular fundus is imperative in the diagnosis and treatment of many acute medical and neurologic conditions, but direct ophthalmoscopy is underused and difficult to perform without pharmacologic pupillary dilation. We believe that nonmydriatic ocular fundus photography (i.e., performed without pupillary dilation) represents a promising alternative to direct ophthalmoscopy, particularly in the emergency department, where limited training in ophthalmoscopy, increased demands on physicians' time, and underappreciation of the prognostic value of ocular fundus examination can place patients at risk for poor outcomes and expose their caregivers to medicolegal liability. The FOTO-ED (Fundus Photography vs. Ophthalmoscopy Trial Outcomes in the Emergency Department) study hypothesized that the use of nonmydriatic fundus photography in the emergency department would result in increased detection of abnormalities in the ocular fundus relevant to emergency-department care, a majority of which would be missed during routine clinical practice in the department.

Introduction: Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IV hypertensive retinopathy. Methods: A preplanned subanalysis of patients who presented to a university hospital ED with diastolic BP ≥ 120 mmHg and who enrolled in the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED study was performed. Bilateral nonmydriatic ocular fundus photographs, vital signs, and demographics were obtained at presentation. Past medical history, laboratory values, healthcare utilization, and mortality were ascertained from medical record review at least 8 months after initial ED visit. Results: Twenty-one patients with diastolic BP ≥ 120 mmHg, 7 of whom (33%) had grade III/IV hypertensive retinopathy, were included. Patients with retinopathy were significantly younger than those without (median 33 vs 50 years, P= 0.02). Mean arterial pressure (165 vs 163 mmHg) was essentially equal in the 2 groups. Patients with retinopathy had substantially increased but nonsignificant rates of ED revisit (57% vs 29%, P = 0.35) and hospital admission after ED discharge (43% vs 14%, P = 0.28). One of the patients with retinopathy died, but none without. Conclusion: Younger patients may be at higher risk for grade III/IV hypertensive retinopathy among patients with hypertensive urgency. Chronic compensatory mechanisms may have not yet developed in these younger patients. Alternatively, older patients with retinopathy may be underrepresented secondary to increased mortality among these patients at a younger age (survivorship bias). Further research is needed to validate these preliminary findings.

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/m2 (odds ratio [OR]: 2.3, p = 0.02), younger age (OR: 0.7 per 10-year increase, p = 0.02), and higher mean arterial blood pressure (OR: 1.3 per 10-mm Hg increase, p = 0.003) were predictive of abnormal retinal photography. Patients with an abnormal fundus had a higher percentage of hospital admission (21% vs 10%, p = 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.

The widespread use of smartphones, provides a unique opportunity for telemedicine. In ophthalmology, smartphones are used for visual acuity assessments and to document examinations, particularly in settings like the emergency department (ED), where the usual ophthalmic tools and photographic services are unavailable. However, to our knowledge, these devices have not been used for systematic, remote review of clinical photographs, as they have in radiology and dermatology. We performed a pilot investigation to compare the quality of non-mydriatic fundus photographs displayed on an iPhone 3G versus a desktop computer.

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.