Portable fundoscopy devices may be key to detecting fundus pathology in neurology inpatients, according to Australian research that found the complication was highly prevalent and often missed by standard ophthalmology tests.
A study of 79 patients admitted to Westmead Hospital for neurological conditions between February and March 2020 found 14% had neurologically-relevant fundus pathology, yet direct ophthalmoscopy picked up zero abnormalities in the five tested patients.
Despite being standard practice and fundoscopy’s crucial role in non-invasively visualising the brain and vasculature during a neurological exam, direct ophthalmoscopy is “rarely performed in the clinical setting” said researchers. This was likely due to “lack of confidence in the skill, insufficient time, senior discouragement, lack of equipment” and belief that the test is futile, they suggested.
Alternatives, such as portable non-mydriatic cameras (NMFP) and smartphone fundoscopy (SF) seem promising and “diagnostically superior” to standard fundoscopic practice, well-tolerated by patients and feasibly implementable in routine inpatient care, the authors wrote in the European Journal of Neurology.
Their prospective cross-sectional surveillance and diagnostic accuracy study found neurologically-relevant optic disc pallor, disc swelling and hypertensive retinopathy in seven, three and one patient, respectively.
While direct ophthalmoscopy failed to show any abnormality, smartphone fundoscopy captured 30–40% of pathologies and NMFP picked up 46%. The former had a lower screening failure rate (1% vs 13%, P < 0.001), 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) than NMFP, though, the authors wrote.
“Our study demonstrates a clinically significant prevalence of fundus pathology amongst neurology inpatients, which was missed by current fundoscopy practices,” they wrote.
Accurate detection and diagnosis are critical since they can affect patient management pathways, they said.
“For example, disc pallor in both multiple sclerosis patients may indicate previous clinical or subclinical optic neuritis, potentially fulfilling criteria for dissemination in time and location which may impact management.”
“In other cases such as myasthenia gravis or iatrogenic subclavian artery dissection, where disc pallor is less likely to be related to the condition, further investigation and correlation with clinical picture is warranted.”
Conversely, recognising normal retinas and optic discs helps prevent unnecessary referrals and investigations, they added.
This “[reinforces] the importance of a reliable fundus examination within a standard neurology examination”, the paper read.
Although the study had several limitations, including its small sample size, and the NMFP and smartphone fundoscopy couldn’t capture all pathologies individually, the technologies seemed “diagnostically superior to routine fundoscopic practice, feasible, and well tolerated by patients”, they wrote.
Their portability, handheld nature, short imaging time, capacity to function without pupil dilation (though smartphone fundoscopy works better with it) and ease-of-use make them well-suited to hospital wards, they suggested, adding that practitioners learned to operate the tools within an hour of training.
Additionally, smartphones are ubiquitous, can be fitted with fundoscopy lens adapters and have high storage capacity and video capabilities, allowing users to document spontaneous venous pulsations and confirm normal intracranial pressure.
More studies are needed to determine these findings’ generalisability, along with the technologies’ cost-effectiveness and clinical impact for patients but, based on this study, NFMP and smartphone fundoscopy have the potential for great utility in clinical practice, the authors concluded.