AAO 2024: Fundus photography/OCT expediates care in the emergency department

Victoria Biousse, MD, from the Emory University in Atlanta, Georgia, shared insights on how ocular imaging in the emergency department can provide timely, accurate diagnosis while also benefiting the on-call ophthalmologists. She shared these thoughts at this year's AAO meeting held in Chicago, Illinois.

Video Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Victoria Biousse, MD:

I am Valerie Biousse, a neuro-ophthalmologist at Emory University in Atlanta. I am a big fan of having non-mydriatic fundus cameras in emergency departments, and we have a few presentations on this topic at the AAO meeting.

As you know, nobody really uses ophthalmoscopes in emergency departments anymore, and cameras are great because they facilitate the examination of the ocular fundus by non ophthalmologists, and they also allow for remote interpretation of the pictures by ophthalmologists. So instead of ophthalmoscopes, we have a camera connected to our electronic health record with an entirely automated process and integration of the camera into the ED flow.

This has proven very useful, because the camera allows the ophthalmologist on call to make some diagnosis remotely, without in person consultation. So for example, if an acute central retinol artery occlusion is abuse on ocular imaging, we do not even come to the hospital anymore, and instead, we trigger a stroke alert, which prompts neurology to take care of the patient immediately, and not having to wait for an ophthalmologist to come to the emergency department or wait for pupillary dilation to look at the fundus is saving a lot of time, and it is allowing us to occasionally recommend treatment of acute central retinol artery oclusion with thrombolysis within just a few hours of vision loss, which is amazing. That has allowed us to design a nice stroke protocol, which has become standard of care at our institution.

Another great use of the camera in the emergency department is when a patient has headaches or is sent to the emergency department to roll out papilledema, presumably from a neurologic disorder. In this case, we just review the pictures remotely, instead of having to come to the ED in the middle of the night for a fundus examination. We showed that this new flow has reduced the ED length of stay by at least 50% for patients sent to the ED mostly to rule out papilledema, and that more than 90% of patients were able to have papilledema ruled out remotely, without an in-person consultation. And you can imagine that this has made our on-call ophthalmologists, including our residents, very happy. So these are the main reasons why I think we really need to work at helping our emergency department colleagues implement such cameras in general emergency departments, especially given the anticipated worsening shortage of ophthalmologists and neuro-ophthalmologists in our country.

Being able to provide adequate ophthalmic examinations in the ED, including remotely, with either implementation of e-consultation or teleophthalmology will become essential, and cameras will help us do that. To take the pictures are obtained directly by the ED staff, and anyone can do it. Currently, we have the technicians who are in charge of doing EKGs in the ED, they were trained. The training takes about 10 minutes. They take the pictures themselves, and that's why the key is to have a very user-friendly camera with only 1 button to push and the pictures happen.

The interpretation is a little more complex. The pictures are readily available to the ED providers and to the neurologists on the electronic medical records. Some of them are comfortable reviewing the pictures themselves, and they interpret them without our help. And it's particularly useful when the pictures are normal. So for example, if all they want to do is rule out papilledema, then in most situations, they do it themselves, and they don't even call us.

On the other hand, if the picture looks abnormal, they page us, and we review the pictures live for them so that they get an immediate interpretation. In all cases, I always reassure them. We tell them, "we have your back," because in all cases, 1 ophthalmologist reviews the pictures, usually within 24 hours, in order to double check that the original interpretation was correct and to be able to bill.