Cédric Lamirel

Nonmydriatic digital ocular fundus photography on the iPhone 3G: the FOTO-ED study.

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Feasibility of nonmydriatic ocular fundus photography in the emergency department: Phase I of the FOTO-ED study.

OBJECTIVES Examination of the ocular fundus is imperative in many acute medical and neurologic conditions, but direct ophthalmoscopy by nonophthalmologists is underutilized, poorly performed, and difficult without pharmacologic pupillary dilation. The objective was to examine the feasibility of nonmydriatic fundus photography as a clinical alternative to direct ophthalmoscopy by emergency physicians (EPs). METHODS Adult patients presenting to the emergency department (ED) with headache, acute focal neurologic deficit, diastolic blood pressure ≥ 120 mm Hg, or acute visual change had ocular fundus photographs taken by nurse practitioners using a nonmydriatic fundus camera. Photographs were reviewed by a neuroophthalmologist within 24 hours for findings relevant to acute ED patient care. Nurse practitioners and patients rated ease, comfort, and speed of nonmydriatic fundus photography on a 10-point Likert scale (10 best). Timing of visit and photography were recorded by automated electronic systems. RESULTS A total of 350 patients were enrolled. There were 1,734 photographs taken during 230 nurse practitioner shifts. Eighty-three percent of the 350 patients had at least one eye with a high-quality photograph, while only 3% of patients had no photographs of diagnostic value. Mean ratings were ≥ 8.7 (standard deviation [SD] ≤ 1.9) for all measures. The median photography session lasted 1.9 minutes (interquartile range [IQR] = 1.3 to 2.9 minutes), typically accounting for less that 0.5% of the patients total ED visit. CONCLUSIONS Nonmydriatic fundus photography taken by nurse practitioners is a feasible alternative to direct ophthalmoscopy in the ED. It is performed well by nonphysician staff, is well-received by staff and patients, and requires a trivial amount of time to perform.

Optical coherence tomography (OCT) in optic neuritis and multiple sclerosis.

Optical coherence tomography (OCT) is a non-invasive imaging technique routinely used in ophthalmology to visualize and quantify the layers of the retina. It also provides information on optic nerve head topography, peripapillary retinal nerve fiber layer thickness, and macular volume, which correlate with axonal loss. These measurements are of particular interest in optic neuropathies and in multiple sclerosis, and OCT parameters are now used as endpoints in neurologic clinical trials.

Quality of Nonmydriatic Digital Fundus Photography Obtained by Nurse Practitioners in the Emergency Department: The FOTO-ED Study

OBJECTIVE Nonmydriatic fundus photography by non-ophthalmic-trained personnel has recently been shown to be a potential alternative to direct ophthalmoscopy in the emergency department (ED). We evaluated the reliability of a novel quality rating scale and applied this scale to nonmydriatic fundus photographs taken during routine ED patient encounters to determine factors associated with diminished photograph quality. DESIGN Prospective, cross-sectional study. PARTICIPANTS We included 350 patients enrolled in the Fundus photography versus Ophthalmoscopy Trials Outcomes in the Emergency Department study who were photographed by nurse practitioners after <30 minutes of training followed by supervision. METHODS Photographs of both eyes were graded for quality on 2 occasions by 2 neuro-ophthalmologists. Four regions were independently evaluated for quality: Optic disc, macula, and superior and inferior vascular arcades. Quality as a function of the number of photographs taken was evaluated by Kaplan-Meier analysis. Mixed effects ordinal logistic regression was used to evaluate for predictors of image quality while accounting for the repeated measures design. MAIN OUTCOME MEASURES Overall photographic quality (1-5 scale; 5 best). RESULTS We evaluated 1734 photographs. Inter- and intraobserver agreements between neuro-ophthalmologists were very good (weighted kappa, 0.84-0.87). Quality of the optic disc area was better than those of other retinal areas (P<0.002). Kaplan-Meier analysis showed that if a high-quality photograph of an eye was not obtained by the third attempt, it was unlikely that one would be obtained at all. A 10-second increase in the interphotograph interval before a total of 40 seconds increased the odds of a 1-unit higher quality rating by 1.81 times (95% confidence interval [CI], 1.68-1.98), and a 10-year increase in age decreased the odds by 0.76 times (95% CI, 0.69-0.85). Black patients had 0.42 times (95% CI, 0.28-0.63) the odds of a 1-unit higher quality rating compared with whites. CONCLUSIONS Our 5-point scale is a reliable measure of nonmydriatic photograph quality. The region of interest, interphotograph interval, and patient age and race are significant predictors of image quality for nonmydriatic photographs taken by nurse practitioners in the ED. Addressing these factors may have a direct impact on the successful implementation of nonmydriatic fundus photography into the ED.

Impaired Saccadic Eye Movement in Primary Open-angle Glaucoma

Purpose:Our study aimed at investigating the extent to which saccadic eye movements are disrupted in patients with primary open-angle glaucoma (POAG). This approach followed upon the discovery of differences in the eye-movement behavior of POAG patients during the exploration of complex visual scenes. Methods:The eye movements of 8 POAG patients and 4 healthy age-matched controls were recorded. Four of the patients had documented visual field scotoma, and 4 had no identifiable scotoma on visual field testing. The eye movements were monitored as the observers watched static and kinetic targets. The gain, latency, and velocity-peak latency of the saccades recorded were then analyzed. Results:In POAG patients, with abnormal visual fields, watching a static target, the saccades were delayed and their accuracy was reduced, compared with those of normal observers. In POAG patients, with normal and abnormal visual fields, watching a kinetic target, a task involving precise motion analysis, the latency and accuracy of the saccades were impaired, compared with those of normal observers. Conclusions:Our findings suggest that POAG alters saccade programming and execution particularly in the case of moving targets.

Never too old to harbour a young man's disease?

An 87-year-old male patient was referred for evaluation of rapidly progressive sequential painless visual loss, occurring 2 months earlier. The right eye was first affected, and at that time the examination performed by the treating ophthalmologist was within normal limits. One month later, rapid progressive visual loss occurred in the remaining eye. In each eye, visual loss occurred over a few days, with no subsequent changes. The patient had a previous history of prostate adenocarcinoma in remission and mild, treated arterial hypertension. He had an otherwise unremarkable personal medical history, and an ophthalmological examination performed 6 months earlier was normal in both eyes. The patient disclosed several members of the family with blindness: his brother with onset at the age of 30, his sisters son (age of onset was unknown) and his sisters daughter with onset at the age of 3. On examination, visual acuity was hand movements in the right eye and 20/30 in the left eye. There was no relative afferent pupillary defect and no proptosis and ocular motility was normal. Slit-lamp examination was within normal limits and intraocular pressure was 16 mm Hg in both eyes. Funduscopy disclosed mild optic disc palor, with no pathological excavation in both eyes, but the remainder of the examination was normal. Goldmann visual fields disclosed severe impairment in both eyes, with remaining peripheral islands of vision inferiorly and temporally (figure 1). In the left eye, the visual field loss spared the inferior central area, explaining the residual visual acuity. The remainder of the neurological and general examination was normal. Figure 1 Goldman visual fields …

Feasibility and quality of nonmydriatic fundus photography in children

PURPOSE Ocular funduscopic examination is difficult in young children and is rarely attempted by nonophthalmologists. Our objective was to determine the feasibility of reliably obtaining high-quality nonmydriatic fundus photographs in children. METHODS Nonmydriatic fundus photographs were obtained in both eyes of children seen in a pediatric ophthalmology clinic. Ease of fundus photography was recorded on a 10-point Likert scale (10 = very easy). Quality was graded from 1 to 5 (1, inadequate for any diagnostic purpose; 2, unable to exclude all emergent findings; 3, only able to exclude emergent findings; 4, not ideal, but still able to exclude subtle findings; and 5, ideal quality). The primary outcome measure was image quality by age. RESULTS A total of 878 photographs of 212 children (median age, 6 years; range, 1-18 years) were included. Photographs of at least one eye were obtained in 190 children (89.6%) and in both eyes in 181 (85.3%). Median rating for ease of photography was 7. Photographs of some clinical value (grade ≥2) were obtained in 33% of children <3 years and 95% ≥3 years. High-quality photographs (grade 4 or 5) were obtained in both eyes in 7% of children <3 years, 57% of children ≥3 to <7 years, 85% of children ≥7 to <9 years, and 65% of children ≥9 years. The youngest patient with high-quality photographs in both eyes was 22 months. CONCLUSIONS Nonmydriatic fundus photographs of adequate quality can be obtained in children over age 3 and in some children as young as 22 months.

A prospective photographic study of the ocular fundus in obstructive sleep apnea

Background: The prevalence of optic nerve and retinal vascular changes within the obstructive sleep apnea (OSA) population are not well-known, although it has been postulated that optic nerve ischemic changes and findings related to an elevated intracranial pressure may be more common in OSA patients. We prospectively evaluated the ocular fundus in unselected patients undergoing overnight diagnostic polysomnography (PSG). Methods: Demographic data, medical/ocular history, and nonmydriatic fundus photographs were prospectively collected in patients undergoing PSG at our institution and reviewed for the presence of optic disc edema for which our study was appropriately powered a priori. Retinal vascular changes were also evaluated. OSA was defined using the measures of both sleep-disordered breathing and hypoxia. Results: Of 250 patients evaluated in the sleep center, fundus photographs were performed on 215 patients, among whom 127 patients (59%) had an apnea/hypopnea index (AHI) ≥15 events per hour, including 36 with severe OSA. Those with AHI <15 served as the comparison group. None of the patients had optic disc edema (95% confidence interval [CI]: 0%–3%). There was no difference in rates of glaucomatous appearance or pallor of the optic disc among the groups. Retinal arteriolar changes were more common in severe OSA patients (odds ratio: 1.09 per 5 unit increase in AHI; 95% CI, 1.02–1.16; P = 0.01), even after controlling for mean arterial blood pressure. Conclusions: We did not find an increased prevalence of optic disc edema or other optic neuropathies in our OSA population. However, retinal vascular changes were more common in patients with severe OSA, independent of blood pressure.

Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure

Introduction: Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IV hypertensive retinopathy. Methods: A preplanned subanalysis of patients who presented to a university hospital ED with diastolic BP ≥ 120 mmHg and who enrolled in the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED study was performed. Bilateral nonmydriatic ocular fundus photographs, vital signs, and demographics were obtained at presentation. Past medical history, laboratory values, healthcare utilization, and mortality were ascertained from medical record review at least 8 months after initial ED visit. Results: Twenty-one patients with diastolic BP ≥ 120 mmHg, 7 of whom (33%) had grade III/IV hypertensive retinopathy, were included. Patients with retinopathy were significantly younger than those without (median 33 vs 50 years, P= 0.02). Mean arterial pressure (165 vs 163 mmHg) was essentially equal in the 2 groups. Patients with retinopathy had substantially increased but nonsignificant rates of ED revisit (57% vs 29%, P = 0.35) and hospital admission after ED discharge (43% vs 14%, P = 0.28). One of the patients with retinopathy died, but none without. Conclusion: Younger patients may be at higher risk for grade III/IV hypertensive retinopathy among patients with hypertensive urgency. Chronic compensatory mechanisms may have not yet developed in these younger patients. Alternatively, older patients with retinopathy may be underrepresented secondary to increased mortality among these patients at a younger age (survivorship bias). Further research is needed to validate these preliminary findings.

Vascular Neuro-ophthalmology

Publisher Summary Visual difficulties are common in patients with stroke. The clinical presentation varies depending on the type of vessel involved (arteries versus veins), the type of stroke (ischemic or hemorrhagic), the size of the arteries involved (small- versus large-artery disease) and the mechanisms of ischemia (embolic, thrombotic, or hemodynamic). Most ocular syndromes and neuroophthalmologic manifestations of stroke vary based on those characteristics and mechanisms. In ischemic arterial cerebrovascular disease, neuroophthalmic symptoms and signs mostly depend on the size and the territory of the artery involved. The retinal microvascular changes are related to incidents of clinical stroke, stroke mortality, coronary artery disease, cerebral white matter changes detected by MRI, and cerebral atrophy. Both infectious and noninfectious inflammation affecting the central nervous system can produce visual symptoms. Patients with systemic hypertension may develop a severe encephalopathy often associated with reversible visual loss. A variety of other systemic disorders producing strokes associated with ocular abnormalities are discussed. The visual pathways are particularly vulnerable to any decrease in their blood or oxygen supply. The effects of decreased cerebral perfusion on visual function vary mostly depending on the collateral circulation. Visual loss may also result from unilateral or bilateral infarction of the retina or optic nerve. The type of neuro-ophthalmic signs depends mostly on the anatomical location of the lesion. Whereas, Terson syndrome describes retinal, subhyaloid, and vitreal hemorrhage that occurs in the setting of subarachnoid hemorrhage. The chapter also discusses embolism, anterior and posterior large-artery circulation ischemia which is often associated with visual symptoms and signs that may precede a cerebral infarction, and primary and secondary intracerebral hemorrhages that may produce visual field defects and abnormal eye movements.Cerebrovascular diseases are commonly associated with neuro-ophthalmologic symptoms or signs, which mostly depend on the type, the size and the location of the vessels involved, and the mechanism of the vascular lesion. Funduscopic examination allows direct visualization of the retinal circulation which shares many common characteristics with the cerebral microcirculation, and can be used as a marker of vascular disease