Non-Mydriatic Ocular Fundus Imaging in a General Emergency Department: Feasibility and Novel Considerations for Systematic Screening.

Abstract

OBJECTIVE To investigate the feasibility of systematic ocular imaging of consecutive patients presenting to our emergency department (ED) with chief complaints for which ocular funduscopic examination is standard of care. DESIGN Prospective quality improvement feasibility project. SUBJECTS Consecutive patients presented to our general ED fulfilling one or more of the following criteria: current vision complaints, headaches, neurologic/neurosurgical disorders, hypertensive crisis, diabetes mellitus, or end-stage renal disease. METHODS Study personnel acquired table-top non-mydriatic ocular fundus photographs with optical coherence tomography of the posterior pole (NMFP-OCT) on consecutive patients presenting to our ED over 16 consecutive days/nights with complaints that would warrant an ophthalmology evaluation, including vision complaints, headaches, neurologic/neurosurgical disorders, hypertensive crisis, diabetes mellitus, or end-stage renal disease. MAIN OUTCOME MEASURES Demographic information, indication for NMFP-OCT, findings, quality of NMFP/OCT, number of NMFP-OCT, and reasons why NMFP-OCT were not taken were documented. RESULTS Among 1838 ED visits over 16 days, orders for NMFP-OCT were placed for 801 patients (43.6%). 410/801 patients (51%) received NMFP-OCT in the ED; 391/801 patients (49%) did not. 93/410 with NMFP-OCT (22.7%) versus 23/391 without NMFP-OCT (5.9%) had vision complaints (p<0.001), 99/410 (24.1%) versus 35/391 (9%) had headaches (p<0.001), 125/410 (30.5%) versus 164/391 (41.9%) had neurological/neurosurgical disorders (p<0.05), 4/410 (1%) versus 4/391 (1%) had hypertensive crisis, and 76/410 (18.5%) versus 132/391 (33.8%) had diabetes. Demographics were similar in both groups. 220/391 patients (56.3%) did not have NMFP-OCT for medical reasons (47.3% too sick/unable to sit, 9% infectious precautions); 171/391 (43.7%) did not have NMFP-OCT because of process problems in the ED. Few ocular imaging studies (6.7%) was uninterpretable. CONCLUSION Despite 24/7 coverage of the ED by our team, 49% of patients did not have NMFP-OCT for reasons related to underlying patient illness or specific to the ED setting. Realistic expectations are needed when considering the feasibility of implementation of new ophthalmic technology in the ED.