Fundoscopic Exam in the ED

[DB2013EM]

Hey y'all. Question from a 4th Year Medical Student for Attendings and Residents.

So with my limited ED experience (5 rotations) I have seen minimal use of the ophthalmoscope and slit lamp. I have seen the slit lamp used 2-3 times, and the ophthalmoscope used about 10. Never seen it used in Hypertension cases, and only see it in trauma or headache or eye pain type cases.

My questions are....

1. Do you use these tools? Why or Why Not?
2. What cases prompt you to use them?
3. Do you feel comfortable with the exam you get?

Naturally, I'm an EM amateur, and I admit relative ignorance in the value of these tools, but just curious as to the utility of these gadgets in the ED.

Thanks

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[Rendar5]

slit lamp I use for all red eye cases, eye pain cases, FB to eye cases
ophthalmoscope I use for certain h/a cases and vision loss cases such as r/o retinal detachment.

I use slit lamp a lot more often than I use fundoscopy as vision loss cases are rare, and the rare h/a cases that it is useful in do not come around regularly .

I feel quite comfortable with the slit lamp except when it comes to definitively finding cells (only seen it once and spoken with senior ophtho residents who find that they don't get good at that part of the exam until after doing it for a year). I rarely feel comfortable with fundoscopy. The big reason being we do not dilate our patient's eyes, and this prevents you from easily seeing everything on many patients. I don't routinely do fundoscopy on hypertensive patients because whether or not there are eye findings does not change my diagnosis, workup, or disposition.

 

[NERDY]

5 rotations?

 

[PAGuy77]

We're a small ER and don't have a slit lamp, or even Optho on call. We have a woods lamp, Tetracaine and Flouroscein (for corneal abrasions). Recently had a nasty looking eye s/p fall with a h/o corneal transplant so I had to transfer him to the Trauma center close by. I scanned his orbits before he left and he wound up having a globe rupture.

I have never seen my attendings use an optholmoscope, only penlight...

 

[monkeybutt]

Ultrasound is becoming a big part of my eye exam. I've diagnosed two retinal detachments and one vitreous hemorrhage via ultrasound. I'm not good enough, but I've had attendings who are comfortable evaluating the optic nerve looking for pseudotumor via ultrasound.

 

[Rendar5]

Ultrasound is becoming a big part of my eye exam. I've diagnosed two retinal detachments and one vitreous hemorrhage via ultrasound. I'm not good enough, but I've had attendings who are comfortable evaluating the optic nerve looking for pseudotumor via ultrasound.

If you can diagnose retinal detachment, you can diagnose papilledema. (you can't diagnose pseudotumor, just papilledema on u/s).

 

[bartleby]

A slit lamp is a necessity for evaluating eye complaints. Once you get comfortable using it, it takes minimal additional time and provides an infinitely better exam.

Getting to know how to use an ophthalmoscope is also key. You don't need it often, but it is very helpful for ruling out papilledema. Especially when you are looking to avoid performing a ct scan in someone with a benign headache, being able to document a thorough exam supports your clinical reasoning. Ultrasound is far more helpful for evaluating for retinal detachment in a non dilated exam as the poster above pointed out.

 

[KarlPilkington]

After talking with my lawyer "friends":

All patients with elevated BP get a fundoscopic exam, both in the room, and in the chart.

All headache patients get a fundoscopic exam both in the room and in the chart.

While I'm not 100%, the more I try to do, the more I see.


The opthalmoscope is on the wall in every patient room in the country, if you read the basic EM core texts, all HA and HTN pts need a fundoscopic exam. If you miss a SAH, HTN emergency...that chart looks a whole lot better if you used all of your available tools at the bedside.

Also, there's a lot to be said for the "smoke and mirrors" of medicine. Pts. love it when a doctor looks in their ears and eyes.

 

[e30ftw]

After talking with my lawyer "friends":

All patients with elevated BP get a fundoscopic exam, both in the room, and in the chart.

gonna call BS on this one... regardless of the masses of 142/83 patients you will see every day... if you do a detailed enough fundoscopic exam to change management on a non dilated patient (which takes a good 2-3 minutes in low light to look at all 4 quadrants and find the disk) who is HTN, diaphoretic w/ severe CP radiating to back, etc.. or ANY patient in extremis with htn, you are delaying actual treatment.

I do fundoscopic exams on nonemergent htn emergency/crisis and pseudo tumor patients so I can feel warm and fuzzy and document.

prolly bust out the ophtho scope once a shift or so, but its never changed my management. U/S is better on a non dilated eye for papilledema.

 

[Hamhock]

You don't need it often, but it is very helpful for ruling out papilledema. .

I would argue that it is not that helpful for ruling-out papilledema in the hands of most providers.

With a non-dilated exam, the majority of EM and IM residents I supervise dramatically over-estimate their ability to identify papilledema. Often presentations include such statements as, "...and there's no papilledema" on fundoscopic exam.

Really? How many times have you seen papilledema? How many times have you seen it and then had it compared to a gold -- or bronze -- standard? How many times have you thought you didn't see it and found out that you just missed it?

That is, what do you think your sensitivity and specificity for this exam (test, really) is? ...and depending on the prevalence in "your population", what do you think your NPV/PPV is?

Although subconciously I suspect most people admit to themselves that their fundoscopic exam is not that good, I often see crucial decisions regarding life-threatening diagnoses made on "there's no papilledema" on fundoscopic exam.

...and that is not including my thoughts on the highly suspect ultrasound measurement of nerve sheath diameter.

HH

Now for patients and lawyers, who are not interested in good medicine -- but prefer the dog and pony show, I refer folks to Pilkington's post.

 

[WilcoWorld]

I would argue that it is not that helpful for ruling-out papilledema in the hands of most providers.

With a non-dilated exam, the majority of EM and IM residents I supervise dramatically over-estimate their ability to identify papilledema. Often presentations include such statements as, "...and there's no papilledema" on fundoscopic exam.

Really? How many times have you seen papilledema? How many times have you seen it and then had it compared to a gold -- or bronze -- standard? How many times have you thought you didn't see it and found out that you just missed it?

That is, what do you think your sensitivity and specificity for this exam (test, really) is? ...and depending on the prevalence in "your population", what do you think your NPV/PPV is?

Although subconciously I suspect most people admit to themselves that their fundoscopic exam is not that good, I often see crucial decisions regarding life-threatening diagnoses made on "there's no papilledema" on fundoscopic exam.

...and that is not including my thoughts on the highly suspect ultrasound measurement of nerve sheath diameter.

HH

Now for patients and lawyers, who are not interested in good medicine -- but prefer the dog and pony show, I refer folks to Pilkington's post.

Exactly. Feel free to put on a good show, just don't let it muck up your medical decision making.

 

[deuist]

I've never seen papilledema, or at least knew that I was looking at it. Many of the eye pieces on our ancient wall-mounted ophthalmoscopes don't line up with the light sources, meaning that I can't see anything anyway. Our slit lamp is constantly in some state of disrepair. And until a few months ago, the tonopen was constantly broken, too. I'm not skilled enough with an ultrasound to start making diagnoses like nerve sheath diameters (and let's be honest about the spotty evidence). So unless the patient has a corneal abrasion or an elevated intraocular pressure, I place a call to ophthalmology to see the patient in the ED.

 

[OPPforlife]

I've never seen papilledema, or at least knew that I was looking at it. Many of the eye pieces on our ancient wall-mounted ophthalmoscopes don't line up with the light sources, meaning that I can't see anything anyway. Our slit lamp is constantly in some state of disrepair. And until a few months ago, the tonopen was constantly broken, too. I'm not skilled enough with an ultrasound to start making diagnoses like nerve sheath diameters (and let's be honest about the spotty evidence). So unless the patient has a corneal abrasion or an elevated intraocular pressure, I place a call to ophthalmology to see the patient in the ED.

Are you in a community based ER?


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[NewmansOwn]

I'm surprised no one has mentioned the pan-optic yet. Is that not a popular thing elsewhere? I pretended to see the backs of eyes all through medical school with an o-scope and then used the pan-optic in residency and found it to be more appropriate for my average intellect and below-average attention to detail and patience.

Slit lamp is a must for small foreign bodies. Also, to avoid missing a small hyphema in trauma patients with a direct hit to the eye or orbit.

Woods' lamp with fluoroscein seems sufficient for corneal abrasions. And Seidel test to r/o globe rupture.

I'm tepid on EM's circle-jerk over ultrasound for anything and everything these days, but retinal and vitreous detachments are fairly easy (and, more importantly, quick) to see on ultrasound.

 

[ERDude]

I'll be honest here (I'm a community attending in a busy practice out 3ish years): I haven't used an ophthalmoscope once since residency. I do use the slit lamp a reasonable amount, but I haven't (and have no plans to) even considered doing a fundoscopic exam.

 

[dchristismi]

I am more likely to check for a red reflex in a kiddo than attempt fundoscopy on a hypertensive grownup.

Someone swiped the lens from our slitlamp last year, and it took months to get it replaced. I have a great optho group though - they bring their own lenses or have the patient go directly to the office - even on weekends.

I love ultrasounding eyeballs.

 

[Birdstrike]

I think it's helpful to do a very quick fundoscopic exam (not a prolonged, pained, and futile one looking for every retinal subtlety known to man) but mainly because a vitreous hemorrhage can be seen immediately and very easily. Anything else you're lucky enough to see can only make you look a little better when you call an ophthalmologist. Anything sounds better than, "I have no clue, I didn't even look in his eye (but that didn't stop me from wasting your time)." Generally, I agree though, it's not worth spending huge amounts of time struggling with, since the subtleties can be so difficult. A lot of it is history.