Nonmydriatic Ocular Fundus Photography Research Articles

Nonmydriatic Retinal Photography in the Outpatient Neurology Resident Clinic.

The funduscopic examination is an essential component of the neurologic examination. However, examination of the ocular fundus with a direct ophthalmoscope is often difficult. Nonmydriatic ocular fundus photography allows direct visualization of the ocular fundus with high-quality photographs. We used nonmydriatic ocular fundus photography to improve patient care and funduscopy skills of residents in the Neurology Resident Clinic. At the time of triage, funduscopic photographs of all new neurology resident clinic patients were taken. The images were imported into the hospital's imaging software. The residents completed a full neurologic examination, including a funduscopic examination with a handheld ophthalmoscope. At the time of staffing the patients with the attendings, the residents received immediate feedback and teaching on retina photograph evaluation. A total of 255 patients were enrolled. Of those, 230 (90%) had at least one high-quality funduscopic photograph. Retinal photographs were normal in 161 (70%). Out of the 69 abnormal photographs, only 7% of abnormalities were detected by the residents. Ninety-three percent of residents found the retinal photographs useful. Nonmydriatic ocular fundus photography improved the care in patients presenting to a Neurology resident clinic and facilitated residents in recognizing funduscopic findings. Its benefits are clear when one considers (1) the high risk of negative patient outcomes and possible medicolegal consequences due to missed findings, (2) the ease of incorporating retinal photographs into the patients' medical records, and (3) the benefit of improving resident education in regard to the ophthalmologic examination.

Feasibility of the Digital Retinography System Camera in the Pediatric Emergency Department.

Direct ophthalmoscopy may be difficult without pupillary dilation and patient cooperation. Nonmydriatic ocular fundus photography (NMOFP) has been shown to be easily and efficiently accomplished by medical providers and improve the detection of abnormalities in adult emergency department (ED) patients. Nonmydriatic ocular fundus photography for pediatric ED patients has not been studied. The purpose of this study was to assess the ease of use of the Digital Retinography System (DRS) camera for NMOFP in ED patients aged 5 to 12 years and the quality of retinal images obtained with the DRS. Retinal images were obtained with the DRS by a pediatric emergency medicine physician using a convenience sample of ED patients aged 5 to 12 years. Time to procedure completion, patient cooperation (Likert scale 1-5, with 5 being most cooperative), and satisfaction with the images (Likert scale 1-5, with 5 being completely satisfied) were recorded. Any satisfaction score less than 5 required the physician to describe a reason for dissatisfaction (brightness, field of view, focus). An ophthalmologist was consulted regarding any abnormal image. The accompanying parent completed a survey following the procedure. Estimated time to completion of the procedure and a rating of the overall comfort and cooperation of the child during the procedure (Likert scale 1-5) were recorded. A second pediatric emergency medicine physician reviewed all images and rated the level of satisfaction, reasons for dissatisfaction, and whether the images were normal. Descriptive statistics were used to analyze survey responses. A Mann-Whitney U test was used to compare continuous data for age groups 5 to 8 and 9 to 12 years. A Krippendorff α or κ coefficient was used to measure agreement between the physician obtaining the images and the secondary reviewer for image satisfaction and image abnormalities. One hundred three patients were enrolled: 50 aged 5 to 8 years and 53 aged 9-12 years (mean, 9.1 [SD, 2.1] years). Five patients failed to cooperate, and no images were obtained. The mean length of time (LOT) to procedure completion was 1.8 (SD, 0.86) minutes. Overall, mean cooperation score was 4.4, and mean image satisfaction score was 4.6. One or more reasons for image dissatisfaction were given in 27 patients (imperfect focus most commonly). There was moderate agreement between the 2 physicians for image satisfaction (Krippendorff α coefficient = 0.48) and image abnormalities (κ coefficient = 0.38). Mean LOT did not differ between 5- to 8-year-olds and 9- to 12-year-olds (P = 0.23). Older patients had higher mean cooperation scores and image satisfaction scores (P < 0.001 and P = 0.04 respectively). Parental mean score for perceived LOT was 4.6 (5 = very short), 4.8 for patient comfort (5 = very comfortable), and 4.8 for patient cooperation (5 = very cooperative). Our data suggest that NMOFP using the DRS camera is a rapid and easy method of obtaining high-quality images of the retina in pediatric ED patients.

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

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

Human Visual System-Based Fundus Image Quality Assessment of Portable Fundus Camera Photographs.

Telemedicine and the medical "big data" era in ophthalmology highlight the use of non-mydriatic ocular fundus photography, which has given rise to indispensable applications of portable fundus cameras. However, in the case of portable fundus photography, non-mydriatic image quality is more vulnerable to distortions, such as uneven illumination, color distortion, blur, and low contrast. Such distortions are called generic quality distortions. This paper proposes an algorithm capable of selecting images of fair generic quality that would be especially useful to assist inexperienced individuals in collecting meaningful and interpretable data with consistency. The algorithm is based on three characteristics of the human visual system--multi-channel sensation, just noticeable blur, and the contrast sensitivity function to detect illumination and color distortion, blur, and low contrast distortion, respectively. A total of 536 retinal images, 280 from proprietary databases and 256 from public databases, were graded independently by one senior and two junior ophthalmologists, such that three partial measures of quality and generic overall quality were classified into two categories. Binary classification was implemented by the support vector machine and the decision tree, and receiver operating characteristic (ROC) curves were obtained and plotted to analyze the performance of the proposed algorithm. The experimental results revealed that the generic overall quality classification achieved a sensitivity of 87.45% at a specificity of 91.66%, with an area under the ROC curve of 0.9452, indicating the value of applying the algorithm, which is based on the human vision system, to assess the image quality of non-mydriatic photography, especially for low-cost ophthalmological telemedicine applications.

A cautionary tale about a global problem.

Direct fundoscopy vs nonmydriatic ocular fundus photography—which is more reliable in untrained hands? I read with interest the editorial on the dying (or rather already dead) ophthalmoscopic skills of neurologists and the advent and superiority of nonmydriatic ocular fundus photography over direct fundoscopic examination. There is a saying that “the eye cannot see what the mind does not know,” and the 2 cases cited by Kattah and Halmagyi1 are examples of this rather than a failure …

Nonmydriatic ocular fundus photography in neurologic emergencies.

The ocular fundus examination is infrequently and poorly performed in clinical settings, placing patients at risk for missed and delayed diagnosis of vision- and life-threatening neurologic disease. To review the importance of ocular fundus examination, the limitations of direct ophthalmoscopy, and the relative merits of nonmydriatic ocular fundus photography in emergency neurologic diagnosis. PubMed queries were reviewed for articles of relevance to this review. Queries included relevant combinations of the search terms ophthalmoscopy, nonmydriatic, neurology, and emergency, including variant spellings and endings. Nonmydriatic ocular fundus photography is more sensitive than direct ophthalmoscopy in several settings. It can be feasibly performed in emergency departments and has substantial promise in improving neurologic diagnosis, particularly headache and cerebrovascular disease. Nonmydriatic ocular fundus photography has notable advantages over direct ophthalmoscopy that likely outweigh its associated costs. More widespread deployment and integration into neurologic practice is expected to improve diagnosis and patient outcomes.

Nonmydriatic Ocular Fundus Photography Among Patients with Focal Neurologic Deficits in an Emergency Department (ED) (P3.096)

Nonmydriatic Ocular Fundus Photography Among Patients with Focal Neurologic Deficits in an Emergency Department (ED) (P3.096)

Nonmydriatic retinal photography in the evaluation of acute neurologic conditions

Ocular fundus examination is a fundamental component of the neurologic examination. Finding papilledema in headache patients or retinal arterial emboli in stroke patients can be extremely useful. Although examination of the ocular fundus with a direct ophthalmoscope is an important skill for all neurologists, it is rarely and unreliably performed. Nonmydriatic ocular fundus photography, which allows direct visualization of high-quality photographs of the ocular fundus, has been recently proposed for screening neurologic patients in urgent care settings such as emergency departments. This new technology has many potential applications in neurology, including e-transmission of images for remote interpretation.

Nonmydriatic retinal photography in the evaluation of acute neurologic conditions

Ocular fundus examination is a fundamental component of the neurologic examination. Finding papilledema in headache patients or retinal arterial emboli in stroke patients can be extremely useful. Although examination of the ocular fundus with a direct ophthalmoscope is an important skill for all neurologists, it is rarely and unreliably performed. Nonmydriatic ocular fundus photography, which allows direct visualization of high-quality photographs of the ocular fundus, has been recently proposed for screening neurologic patients in urgent care settings such as emergency departments. This new technology has many potential applications in neurology, including e-transmission of images for remote interpretation.

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Thulasi et al.1 studied the importance of funduscopic examination in patients with headache. Fundus findings are well-described in noncommunicable diseases such as hypertension, diabetes mellitus, and congenital and hereditary metabolic disorders but not in infectious diseases.2 Retinopathy has been reported in some infectious diseases like malaria, infective endocarditis, cysticercosis, HIV, and dengue.2,3 Fundus findings would aid clinicians in rural settings or underdeveloped environments in reaching a diagnosis depending on the prevalent disease in that area.

Teaching Ophthalmoscopy to Medical Students (the TOTeMS Study)

To determine medical student preferences for learning the ocular fundus examination and to assess their accuracy using different examination modalities. Prospective, randomized study of medical student education approaches. First-year medical students received training in direct ophthalmoscopy using simulators and human volunteers. Students were randomized to receive vs not receive specific training on interpreting fundus photographs prior to accuracy assessments. Students' preferences for each of the 3 methods (direct ophthalmoscopy on simulators or human volunteers, or use of fundus photographs) and recognition of normal and abnormal fundus features were assessed. Of 138 first-year medical students, 119 (86%) completed all required elements. For learning ophthalmoscopy, 85 (71%) preferred humans to simulators. For learning relevant features of the ocular fundus, 92 (77%) preferred photographs to ophthalmoscopy on simulators or humans. Accuracy of answers was better when interpreting fundus photographs than when performing ophthalmoscopy on simulators (P < .001). Performance improved after specific teaching about assessing fundus photographs before testing (P = .02). Examination of the ocular fundus was found easier and less frustrating when using photographs than when using ophthalmoscopy on simulators or humans. Eighty-four students (70%) said they would prefer to have fundus photographs instead of using the ophthalmoscope during upcoming clinical rotations. Students preferred fundus photographs for both learning and examining the ocular fundus. Identification of ocular fundus features was more accurate on photographs compared to examination by direct ophthalmoscopy. In the future, the increasing availability of nonmydriatic ocular fundus photography may allow replacement of direct ophthalmoscopy in many clinical settings for non-ophthalmologists.

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Editors' Note: Direct ophthalmoscopy is sometimes omitted during the neurologic examination, even when it is necessary. There is no definite solution for this issue, Appleton et al. and Bruce et al. agree. But the former endorses appropriate and thorough clinical examination while the latter explains the benefit of nonmydriatic ocular fundus photography, especially when the ocular abnormalities are subtle. Distinguishing behavioral variant frontotemporal dementia (bvFTD) from Alzheimer disease (AD) can be challenging. In response to Hornberger, who argues that episodic memory deficit is a poor diagnostic predictor to discriminate bvFTD from AD, Mendez clarifies that their study looked at a select group of patients …

Diagnostic Accuracy and Use of Nonmydriatic Ocular Fundus Photography by Emergency Physicians: Phase II of the FOTO-ED Study

During the first phase of the Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department study, 13% (44/350; 95% confidence interval [CI] 9% to 17%) of patients had an ocular fundus finding, such as papilledema, relevant to their emergency department (ED) management found by nonmydriatic ocular fundus photography reviewed by neuro-ophthalmologists. All of these findings were missed by emergency physicians, who examined only 14% of enrolled patients by direct ophthalmoscopy. In the present study, we evaluate the sensitivity of nonmydriatic ocular fundus photography, an alternative to direct ophthalmoscopy, for relevant findings when photographs are made available for use by emergency physicians during routine clinical care. Three hundred fifty-four patients presenting to our ED with headache, focal neurologic deficit, visual change, or diastolic blood pressure greater than or equal to 120 mm Hg had nonmydriatic fundus photography obtained (Kowa nonmydriatic α-D). Photographs were placed on the electronic medical record for emergency physician review. Identification of relevant findings on photographs by emergency physicians was compared with a reference standard of neuro-ophthalmologist review. Emergency physicians reviewed photographs of 239 patients (68%). Thirty-five patients (10%; 95% CI 7% to 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). Emergency physicians identified 16 of 35 relevant findings (sensitivity 46%; 95% CI 29% to 63%) and also identified 289 of 319 normal findings (specificity 91%; 95% CI 87% to 94%). Emergency physicians reported that photographs were helpful for 125 patients (35%). Emergency physicians used nonmydriatic fundus photographs more frequently than they performed direct ophthalmoscopy, and their detection of relevant abnormalities improved. Ocular fundus photography often assisted ED care even when results were normal. Nonmydriatic ocular fundus photography offers a promising alternative to direct ophthalmoscopy.

Non-Mydriatic Ocular Fundus Photography among Headache Patients in an Emergency Department (P03.111)

Non-Mydriatic Ocular Fundus Photography among Headache Patients in an Emergency Department (P03.111)

Replacing the Direct Ophthalmoscope: Diagnostic Accuracy and Use of Non-Mydriatic Ocular Fundus Photography by Emergency Department Physicians (Phase II of the FOTO-ED Study) (P02.250)

Replacing the Direct Ophthalmoscope: Diagnostic Accuracy and Use of Non-Mydriatic Ocular Fundus Photography by Emergency Department Physicians (Phase II of the FOTO-ED Study) (P02.250)

Replacing the Direct Ophthalmoscope: Diagnostic Accuracy and Use of Non-Mydriatic Ocular Fundus Photography by Emergency Department Physicians (Phase II of the FOTO-ED Study) (IN4-2.001)

Replacing the Direct Ophthalmoscope: Diagnostic Accuracy and Use of Non-Mydriatic Ocular Fundus Photography by Emergency Department Physicians (Phase II of the FOTO-ED Study) (IN4-2.001)

Nonmydriatic ocular fundus photography among headache patients in an emergency department.

Determine the frequency of and the predictive factors for abnormal ocular fundus findings among emergency department (ED) headache patients. 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. 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/m(2) (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. 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.

Non-Mydriatic Ocular Fundus Photography Read by Emergency Department (ED) Physicians: FOTO-ED Study (P07.264)

Objective: Compare non-mydriatic ocular fundus photography read by ED physicians to their direct ophthalmoscopy. Background In the first phase of the FOTO-ED Study, 12.6% of 350 ED patients with complaints/conditions warranting ocular fundus examination had findings, such as papilledema, that should have altered their management/disposition. Disturbingly, only 14% of these 350 patients had direct ophthalmoscopy performed, and nearly all of the relevant findings were missed and identified solely by fundus photography reviewed by neuro-ophthalmologists. Design/Methods: Patients presenting to our ED with headache, focal neurologic defect, visual change, or diastolic blood pressure ≥120 were prospectively enrolled. Fundus photography was performed by a nurse practitioner or medical student using a non-mydriatic fundus camera (Kowa nonmyd-alpha-D). ED physicians were notified that photographs were available on the electronic medical record, but were not required to review the photographs. Results: 354 patients were included from among 473 assessed for eligibility (exclusions:82 ineligible, 33 refused participation, 3 other reasons). Photographs of 239 (68%) were reviewed by ED physicians. 34 patients (10%) had relevant findings identified by neuro-ophthalmologist review (6 disc edema, 6 grade III/IV HTN retinopathy, 6 isolated hemorrhages, 15 optic disc pallor, and 1 retinal vascular occlusion). 14 of those 34 relevant findings (41%) were identified by the ED physicians, eight (24%) occurred in patients whose photographs were not reviewed by ED physicians, and the remaining were reviewed but recorded as likely normal/normal. The ED physicians reported that the photographs were helpful for 125 patients (35%). Conclusions: Non-mydriatic fundus photographs were used more frequently than direct ophthalmoscopy by ED physicians, and were more sensitive to relevant abnormalities. Ocular fundus photography was more often helpful in ED patient evaluations, even when normal. We plan to investigate whether training in the interpretation of fundus photographs improves ED physician performance and facilitates appropriate ED management. Supported by: In part by an unrestricted departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York, and by NIH/NEI core grant P30-EY06360 (Department of Ophthalmology). Dr. Bruce receives research support from the NIH/NEI (K23-EY019341). Dr. Newman is a recipient of the Research to Prevent Blindness Lew R. Wasserman Merit Award. Disclosure: Dr. Bruce has nothing to disclose. Dr. Thulasi has nothing to disclose. Dr. Fraser has nothing to disclose. Dr. Keadey has nothing to disclose. Dr. Ward has nothing to disclose. Dr. Heilpern has nothing to disclose. Dr. Wright has received (royalty or license fee or contractual rights) payments from Emory University. Dr. Wright holds stock and/or stock options in Zenda Technologies. Dr. Newman has received personal compensation for activities with Biogen Idec. Dr. Biousse has nothing to disclose.

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

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). 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. 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. 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.

Nonmydriatic Ocular Fundus Photography in the Emergency Department

To the Editor: 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.1,2 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.1,3 The FOTO-ED (Fundus Photography . . .