According to a recent study published in Frontiers in Neurology, patients are receiving funduscopic evaluations at insufficient rates from physicians in disciplines other than eye care.1 

The retrospective study reviewed 163 randomly selected charts of patients who presented to the emergency department (ED) with complaints of headaches, altered mental states and visual symptoms such as diplopia and vision loss. For patients complaining of headaches, only 25% were tested with funduscopy, visual symptoms only 26% and altered mental state only 5%. 

“To an emergency doctor, a headache represents a neurological complaint,” says Andrew S. Gurwood, OD. “When tasked with examining a patient with a chief complaint of headache, they know looking inside the eye may provide corroborating information regarding the status of the patient’s general health and whether or not disc edema is present. However, incident stabilization is their priority.”

“One possible explanation for ophthalmoscopy being omitted is the team approach,” Dr. Gurwood adds. “Emergency rooms often have access to eye care departments with experienced practitioners on call. Asking for a consult may, in their minds, ensure the most accurate data is gleaned along with an expert interpretation. Also, emergency physicians not in the practice of doing funduscopy on a routine basis may not have the expertise necessary to view a fundus through an undilated pupil or in the non-optimal environment of the ED.” 

The study accounted for that, too, finding that the ophthalmology department was called in for only 53.4% of the visual symptom cases and 12.5% of headache cases. Possible reasons for this may include insufficient exam time, inadequate practitioner skills, lack of available equipment and a general belief that the technique is not useful.2 

Dr. Gurwood suspects the issue is multifaceted. “Since undilated funduscopy is a practiced skill that requires repetition under the best of conditions, because emergency doctors are not willing to dilate patients in the ED and EDs have ‘phone call’ access to eye care professionals, it’s just easier to ask for a consult to get that data,” Dr. Gurwood says. “I’ll bet they try funduscopy, but when they don’t see inside the eye well, they don’t record that. Instead, they recognize they need that data and make an easy phone call. Looking inside the eye is valuable, no one disputes that; I feel confident no eye care professional would omit the procedure in these cases.”

1. Golombievski E, Doerrier MW, Ruland SD, et al. Frequency of direct funduscopy upon initial encounters for patients with headaches, altered mental status and visual changes: a pilot study. Front Neurol. 2015;(6):233.

2. Roberts E, Morgan R, King D, Clerkin L. Funduscopy: a forgotten art? Postgrad Med J. 1999;75(883):282-4.