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January 29, 2013; 80 (5) Article

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Praneetha Thulasi, Clare L. Fraser, Valérie Biousse, David W. Wright, Nancy J. Newman, Beau B. Bruce
First published January 2, 2013, DOI: https://doi.org/10.1212/WNL.0b013e31827f0f20
Praneetha Thulasi
From the Departments of Ophthalmology (P.T., C.L.F., V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), Neurology (V.B., N.J.N., B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
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Clare L. Fraser
From the Departments of Ophthalmology (P.T., C.L.F., V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), Neurology (V.B., N.J.N., B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
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Valérie Biousse
From the Departments of Ophthalmology (P.T., C.L.F., V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), Neurology (V.B., N.J.N., B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
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David W. Wright
From the Departments of Ophthalmology (P.T., C.L.F., V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), Neurology (V.B., N.J.N., B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
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Nancy J. Newman
From the Departments of Ophthalmology (P.T., C.L.F., V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), Neurology (V.B., N.J.N., B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
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Beau B. Bruce
From the Departments of Ophthalmology (P.T., C.L.F., V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), Neurology (V.B., N.J.N., B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
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Citation
Nonmydriatic ocular fundus photography among headache patients in an emergency department
Praneetha Thulasi, Clare L. Fraser, Valérie Biousse, David W. Wright, Nancy J. Newman, Beau B. Bruce
Neurology Jan 2013, 80 (5) 432-437; DOI: 10.1212/WNL.0b013e31827f0f20

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Abstract

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.

GLOSSARY

BMI=
body mass index;
ED=
emergency department;
EMR=
electronic medical record;
FOTO-ED=
Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department;
HIPAA=
Health Insurance Portability and Accountability Act;
IIH=
idiopathic intracranial hypertension;
IQR=
interquartile range;
OR=
odds ratio

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received May 8, 2012.
  • Accepted September 26, 2012.
  • © 2013 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Re: Fundus examination in emergency department - Author reply
    • Beau B. Bruce, Assistant Professor, Emory Universitybbbruce@emory.edu
    • Beau B. Bruce, Atlanta, GA; Valerie Biousse, Atlanta, GA; Nancy J. Newman, Atlanta, GA
    Submitted May 15, 2013
  • Re: Nonmydriatic ocular fundus photography among headache patients in an emergency department - Author Reply
    • Beau B. Bruce, Assistant Professor, Emory Universitybbbruce@emory.edu
    • Beau B. Bruce, Atlanta, GA; Valerie Biousse, Atlanta, GA; Nancy J. Newman, Atlanta, GA
    Submitted February 22, 2013
  • FUNDUS EXAMINATION IN EMERGENCY DEPARTMENT
    • Khichar Shubhakaran, Associate Professor Neurology, Dr. S. N. Medical College, Jodhpur, Indiadrkhicharsk@gmail.com
    • Rekha Jakhar Khichar
    Submitted February 15, 2013
  • nonmydriatic ocular fundus photography among headache patients in an emergency department
    • Jason Appleton, Neurology SHO, Sandwell and West Birmingham Hospitals NHS Trustjasonappleton@doctors.org.uk
    • Jason Appleton, Birmingham, United Kingdom; David Nicholl, Birmingham, United Kingdom
    Submitted February 15, 2013
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