Consider Optic Nerve Head Edema in Some ED Patients

By Lorraine L. Janeczko

June 02, 2017

NEW YORK (Reuters Health) - Emergency department physicians should check certain patients for optic nerve head edema (ONHE) by fundus photography, researchers say.

"The FOTO-ED study showed that non-mydriatic retinal photography in the emergency department is feasible and may improve patient care and outcomes when systematically performed in patients with a chief complaint of headache, neurologic deficit, visual loss, or elevated blood pressure (BP). Finding ONHE is particularly important in this patient population," the authors reported May 10 at the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO), in Baltimore, Maryland.

"Optic nerve head edema is very serious and may represent life-threatening pathology. Fundus photography is feasible and detects clinically important pathology much better than standard ophthalmoscopy procedures. We think it is time for all EDs to begin to use fundus photography to evaluate patients," co-author Dr. David W. Wright of Emory University School of Medicine in Atlanta, Georgia, told Reuters Health in an email.

"One in 40 patients (2.5%) presenting to the emergency department with a chief complaint of headache, neurologic deficit, visual loss, or elevated BP had ONHE. Our results are consistent with the hypothesis that the identification of ONHE altered the patient disposition and contributed to the final diagnosis, confirming the importance of funduscopic examination in the ED," the authors wrote.

In the cross-sectional analysis of patients presenting to an urban academic emergency department in the United States, Dr. Wright and colleagues assessed the characteristics of the patients diagnosed with ONHE.

Of the 1,429 patients in the study, 36 (2.5%) had ONHE. Twenty-six of these patients presented with bilateral ONHE. The remaining 10 patients presented with unilateral ONHE.

The chief complaints among the patients with ONHE, irrespective of type, included: headache (n=18), acute visual deficit (n=2), acute neurological deficit (n=4), elevated blood pressure (n=2), and both headache and acute visual deficit (n=2).

Final diagnoses included idiopathic intracranial hypertension (n=18), optic neuritis (n=3), and cerebrospinal fluid shunt malfunction/infection (n=3). Two patients each suffered from a brain tumor, non-arteritic ischemic optic neuropathy, cerebral venous sinus thrombosis, or malignant hypertension. One patient each suffered from meningitis, cerebral infarction and neurosarcoidosis, or retinopathy.

Out of the 36 patients, 15 were seen in the emergency department and their referring physician had already diagnosed ONHE. In 21 patients, fundus photographs were the first indication of ONHE in the emergency department. However, the emergency department health care providers identified the presence of ONHE in just five patients. Perhaps most significant, however, was that knowledge of the presence of ONHE changed the final diagnosis in 10 of these patients.

"For years we have known that the eye/fundus exam is a critical part of the physical exam and patient evaluation, but typical ophthalmoscopy is difficult to perform and is often underperformed. Very important pathology can be missed if it is not performed, and fundus photography is a far superior way to accomplish it," Dr. Wright told Reuters Health.

Asked about plans for further related study, he said, "It would be interesting to know the prevalence of underlying disease and abnormalities in the population of patients without the symptoms used for inclusion, such as headache. There are also likely subpopulations of patients in whom even more pathology is expected, which the data may not reflect.

Dr. Wright would also like to know the long-term outcomes of the patients in the study who were missed compared to those who were identified.

"We are continuing to explore how fundus photography can identify patients at risk in the ED,” he said. “For example, can the fundus provide information about the risk of stroke in patients with a transient ischemic attack? Can the fundus exam help identify patients at risk for stroke, and heart disease in patients with acute hypertension?"

"The eye is the window to the brain and can provide a lot of important information," he added.


ARVO 2017.