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The Role of Fundoscopy Before Lumbar Puncture in Children with Suspected Meningitis
Nir Friedman1,2, Or Kaplan3,4, Gidon Test3
1Pediatric Emergency Department, Meir Medical Center, Kfar Saba, Israel.
Insights
Routine fundoscopy before lumbar puncture (LP) in children with suspected meningitis rarely detects papilledema and may delay critical antibiotic treatment. A selective approach is recommended for better care in time-sensitive meningitis cases.
Area of Science:
- Pediatric Emergency Medicine
- Ophthalmology
- Infectious Disease
Background:
- Fundoscopy is frequently used before lumbar puncture (LP) in children with suspected meningitis to identify papilledema and inform neuroimaging decisions.
- Limited evidence exists regarding the diagnostic yield and clinical impact of routine fundoscopy in pediatric emergency settings.
Purpose of the Study:
- To evaluate the diagnostic value and clinical effects of performing fundoscopy prior to lumbar puncture in pediatric patients suspected of having meningitis.
Main Methods:
- A multicenter retrospective cohort study involving 1,742 children (18 months-18 years) across 15 pediatric emergency departments from July 2018 to June 2023.
- Primary outcome: papilledema prevalence. Secondary outcomes: neuroimaging abnormalities, LP deferral, and time to antibiotic administration.
Main Results:
- Papilledema was detected in 2.8% of cases; no contraindications to LP were identified via fundoscopy.
- Fundoscopy was associated with lower rates of early antibiotic administration (42.6% vs. 58.8%) and longer time to antibiotics.
- Children receiving head CT without fundoscopy received antibiotics earlier (239 min vs. 341 min) and more frequently before LP.
Conclusions:
- Routine fundoscopy before LP in children with suspected meningitis has low diagnostic yield for papilledema and does not appear to improve LP safety.
- The procedure may delay essential antibiotic treatment, suggesting a selective, clinically guided approach is preferable.
- Streamlining pre-LP evaluation with a targeted strategy could enhance care for time-critical meningitis presentations.
Purpose:
To assess the diagnostic yield and clinical impact of fundoscopy before lumbar puncture (LP) in children with suspected meningitis.
Methods:
A multicenter retrospective cohort study across 15 pediatric emergency departments, including children aged 18 months-18 years with suspected meningitis between July 2018 and June 2023. The primary outcome was papilledema prevalence; secondary outcomes were subsequent abnormal neuroimaging, LP deferral, and time to antibiotics.
Results:
Among 1,742 children (median age 4.6 years), bacterial meningitis was confirmed in 56 (3.2%). Fundoscopy was performed by ophthalmology residents in 959 (55.1%). Papilledema was identified in 27 (2.8%); all underwent CT, which revealed no contraindications to LP, and all proceeded to LP. Three children with normal fundoscopy who underwent LP were later found to have CT abnormalities (brain abscess and tumor); none of which led to adverse outcomes. Antibiotics were administered before LP less often when fundoscopy was performed (42.6% vs 58.8%, p < 0.001), although median time to antibiotics was similar (341 vs 269 min, p = 0.52). Children who had a head CT without fundoscopy received antibiotics earlier (239 vs 341 min; p = 0.039), and more frequently before LP (64.3% vs 42.6%, p < 0.001).
Conclusions:
Routine fundoscopy before LP rarely detected papilledema, did not identify contraindications to LP, and was associated with lower rates of early antibiotic treatment. These findings suggest that fundoscopy adds little to safe LP decision-making and may inadvertently delay care in time-critical meningitis. A selective, clinically guided pre-LP approach, rather than routine fundoscopy, could streamline evaluation and improve practice.
What Is Known:
• Fundoscopy is often performed before lumbar puncture (LP) in children with suspected meningitis to detect papilledema and guide decision about neuroimaging. • Evidence for its diagnostic yield and clinical impact in pediatric emergency settings is limited.
What Is New:
• In a multicenter cohort of 1,742 children, fundoscopy (performed by ophthalmology residents) detected papilledema in only 2.8% of cases and revealed no contraindications to LP. • Fundoscopy was associated with lower rates of early antibiotic administration.
