Impact on patient management of non-mydriatic fundus photography compared to direct ophthalmoscopy in a regional Australian emergency department

Breaking the barriers: Methodology of implementation of a non-mydriatic ocular fundus camera in an emergency department

Despite evidence that non-mydriatic fundus cameras are beneficial in non-ophthalmic settings, they are only available in a minority of hospitals in the US. The lag from research-based evidence to change in clinical practice highlights the complexities of implementation of new technology and practice. We describe the steps used to implement successfully a non-mydriatic ocular fundus camera combined with optical coherence tomography (OCT) in a general emergency department (ED) using Kotter's 8-Step Change Model. We prospectively collected the number of trained personnel in the ED, the number of imaging studies obtained each week during the first year following implementation, and we documented major achievements each month, as well as outcome measures, barriers to implementation and possible solutions. Between 12 and 42 patients were imaged per week, resulting in a total of 1274 patients imaged demonstrating sustained usage of non-mydriatic fundus camera/OCT in the ED one year after implementation. The implementation process was contingent upon multidisciplinary collaboration, extensive communication, coordinated training of staff, and continuous motivation. The future will likely include the use of artificial intelligence deep learning systems for automated interpretation of ocular imaging as an immediate diagnostic aid for ED or other non-eye care providers.

Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study

OBJECTIVES

Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache.

METHODS

Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination.

RESULTS

5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%).

CONCLUSION

The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning.

TRIAL REGISTRATION NUMBER

ANZCTR376695.

Application of non-mydriatic fundus photography-assisted telemedicine in diabetic retinopathy screening

BACKGROUND

Early screening and accurate staging of diabetic retinopathy (DR) can reduce blindness risk in type 2 diabetes patients. DR's complex pathogenesis involves many factors, making ophthalmologist screening alone insufficient for prevention and treatment. Often, endocrinologists are the first to see diabetic patients and thus should screen for retinopathy for early intervention.

AIM

To explore the efficacy of non-mydriatic fundus photography (NMFP)-enhanced telemedicine in assessing DR and its various stages.

METHODS

This retrospective study incorporated findings from an analysis of 93 diabetic patients, examining both NMFP-assisted telemedicine and fundus fluorescein angiography (FFA). It focused on assessing the concordance in DR detection between these two methodologies. Additionally, receiver operating characteristic (ROC) curves were generated to determine the optimal sensitivity and specificity of NMFP-assisted telemedicine, using FFA outcomes as the standard benchmark.

RESULTS

In the context of DR diagnosis and staging, the kappa coefficients for NMFP-assisted telemedicine and FFA were recorded at 0.775 and 0.689 respectively, indicating substantial intermethod agreement. Moreover, the NMFP-assisted telemedicine's predictive accuracy for positive FFA outcomes, as denoted by the area under the ROC curve, was remarkably high at 0.955, within a confidence interval of 0.914 to 0.995 and a statistically significant P-value of less than 0.001. This predictive model exhibited a specificity of 100%, a sensitivity of 90.9%, and a Youden index of 0.909.

CONCLUSION

NMFP-assisted telemedicine represents a pragmatic, objective, and precise modality for fundus examination, particularly applicable in the context of endocrinology inpatient care and primary healthcare settings for diabetic patients. Its implementation in these scenarios is of paramount significance, enhancing the clinical accuracy in the diagnosis and therapeutic management of DR. This methodology not only streamlines patient evaluation but also contributes substantially to the optimization of clinical outcomes in DR management.

Fundoscopy Use in Neurology Departments and the Utility of Smartphone photography ( FUNDUS ): A prospective prevalence and crossover diagnostic accuracy study amongst neurology inpatients

Background and purpose

Although fundoscopy is a crucial part of the neurological examination, it is challenging, under‐utilized and unreliably performed. The aim was to determine the prevalence of fundus pathology amongst neurology inpatients and the diagnostic accuracy of current fundoscopy practice compared with systematic screening with smartphone fundoscopy (SF) and portable non‐mydriatic fundus photography (NMFP).

Methods

This was a prospective cross‐sectional surveillance and diagnostic accuracy study on adult patients admitted under neurology in an Australian hospital. Inpatients were randomized to initial NMFP (RetinaVue 100, Welch Allyn) or SF (D‐EYE) followed by a crossover to the alternative modality. Images were graded by neurology doctors, using telemedicine consensus neuro‐ophthalmology NMFP grading as the reference standard. Feasibility parameters included ease, comfort and speed.

Results

Of 79 enrolled patients, 14.1% had neurologically relevant pathology (seven, disc pallor; one, hypertensive retinopathy; three, disc swelling). The neurology team performed direct ophthalmoscopy in 6.6% of cases and missed all abnormalities. SF had a sensitivity of 30%–40% compared with NMFP (45.5%); however, it had a lower rate of screening failure (1% vs. 13%, p < 0.001), a shorter examination time (1.10 vs. 2.25 min, p < 0.001) and a slightly higher patient comfort rating (9.2 vs. 8/10, p < 0.001).

Conclusion

Our study demonstrates a clinically significant prevalence of fundus pathology amongst neurology inpatients which was missed by current fundoscopy practices. Portable NMFP screening appears more accurate than SF, whilst both are diagnostically superior to routine fundoscopic practice, feasible and well tolerated by patients.