Nonmydriatic Ocular Fundus Imaging in Consecutive Patients With Headache in an Emergency Department

Ocular fundus findings such as papilledema are red flags in the evaluation of headache but are often missed in emergency departments (EDs), where ocular fundus examination is rarely performed. Our goal was to determine how often nonmydriatic ocular fundus photographs with optical coherence tomography (NMFP-OCT) show relevant ocular fundus findings in a consecutive cohort of patients with headaches in our ED.

This was a quality improvement project conducted prospectively over 16 consecutive days/nights. NMFP-OCT OU (tabletop Maestro2/Topcon-Japan) was ordered for all patients presenting to our ED with active headache or a headache history and were classified into the following categories: group 1: isolated headache evaluation/treatment; group 2: neurologic/neurosurgical issue with associated active headache; group 3: non-neurologic issue with active headache; group 4: headache history but no active headache. Demographic information, headache classification, final diagnosis, and NMFP-OCT findings were collected.

Of 1,838 ED visits over 16 days/nights, 194 patients had headaches or a history of headaches and 149 (76.4%) underwent NMFP-OCT in the ED. In group 1, of the 46 total patients, 40 had NMFP-OCT performed in the ED (1 with papilledema, 1 with dilated vessels from carotid-cavernous fistula, 2 with nonrelevant findings). Group 2 included 46 patients overall, and 37 had NMFP-OCT performed in the ED (4 with papilledema, 4 with relevant retinopathies, 3 with optic atrophy, 7 with nonrelevant findings). Group 3 included 77 patients overall, and 52 had NMFP-OCT performed in the ED (none with papilledema). Group 4 included 25 patients overall (3 with neurologic or neurosurgical issue, 22 with non-neurologic/neurosurgical issue), and 20 had NMFP-OCT performed in the ED (no papilledema, 1 with optic atrophy).

NMFP-OCT obtained in our ED for 129 consecutive patients presenting with active headaches (groups 1-3) allowed for rapid diagnosis of papilledema in 5 patients (3.9%), and other relevant findings in 8 patients (6.2%), with 40 patients (23.6%) not undergoing NMFP-OCT. Among the patients who presented to the ED for non-neurologic reasons with active headaches or those patients with only a history of headaches (groups 3-4), none had papilledema. NMFP-OCT enabled prompt and accurate rule-out of papilledema in patients with headaches presenting to our ED and facilitated rapid and reliable examination of the ocular fundus.