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Yield and clinical efficacy of funduscopic examinations performed in the pediatric emergency room
Anat Segev-Becker1, Miki Har-Gil, Pinhas Fainmesser
1Pediatrics Department, Meir Medical Center, Tel Aviv University, Kfar Saba, Israel.
Insights
Emergency room ophthalmology consultations to rule out papilledema in children often yield normal results, especially when symptoms are recent. Visual complaints may increase the likelihood of diagnosis, but neuroimaging is often unnecessary.
Area of Science:
- Ophthalmology
- Pediatrics
- Emergency Medicine
Background:
- Ophthalmology consultations are frequently requested by emergency physicians to rule out papilledema in children.
- The optimal timing and clinical setting for these examinations, as well as their impact on patient management, are not well-established.
Purpose of the Study:
- To evaluate the diagnostic yield of emergency funduscopic examinations in children.
- To establish the optimal timing and efficacy of ophthalmology consultations for suspected papilledema.
Main Methods:
- Retrospective review of medical records for children aged 0-18 years referred for funduscopic examination from the emergency room.
- Data collected included indications for consultation, duration of symptoms, examination findings, and subsequent management.
Main Results:
- Of 479 children evaluated for papilledema, 6 demonstrated the condition. Most children (60%) had symptoms for less than 24 hours and normal eye exams.
- Headache and head trauma were the most common indications. Visual complaints combined with headache were statistically significant indicators of papilledema.
- 71 children underwent neuroimaging despite normal funduscopic exams; one case of medulloblastoma was diagnosed despite normal funduscopy and prolonged symptoms.
Conclusions:
- The majority of emergency room consultations for suspected papilledema in children reveal normal findings, particularly when symptoms are recent (<24 hours).
- Funduscopic examination yield may increase if visual disturbances are reported.
- Emergency ophthalmology consultation may not be warranted when neuroimaging is considered, except in young infants with neurological signs to rule out non-accidental trauma.
Unlabelled:
Consultations by ophthalmologists to rule out papilledema are frequently requested by emergency room (ER) physicians. The clinical setting and optimal timing for examination are not well established, and the impact on patient management is unclear. We evaluated the yield of emergency funduscopic examinations, aiming at establishing the optimal timing and efficacy of the consultation. The medical records of all children aged 0-18 years referred for funduscopic examinations from the ER between June 2010 and May 2011 were reviewed. Of 19,772 ER visits, 1,920 (9.7 %) were seen by an ophthalmologist and 479 (2.4 %) to rule out papilledema. Headache (44.5 %) and head trauma (18.4 %) were the most common indications. Sixty percent of the 479 patients had been symptomatic for <24 h, all having normal eye exams. Only 6/479, with diverse etiologies, depicted papilledema. Among these six children, visual complaints associating with headache were statistically significant to suggest the presence of papilledema (p = 0.014). Seventy-one of the 479 children underwent neuroimaging studies despite normal funduscopic examinations. A single tumor case (medulloblastoma), symptomatic for weeks, had normal funduscopy.
Conclusion:
The vast majority of ER consultations to rule out papilledema show normal findings, particularly among children with signs and symptoms lasting for <24 h. The yield of funduscopy may be higher if visual disturbances are reported. If neuroimaging studies are considered, emergency room ophthalmological consultation is probably not warranted, except for young infants with neurological signs and symptoms in whom retinal hemorrhages suggestive of physical abuse must be ruled out.
