Using non-mydriatic fundus photography to detect fundus pathology in Australian metropolitan emergency departments: a prospective prevalence and diagnostic accuracy study

Objective: To determine the prevalence of fundus pathology in metropolitan Australian EDs utilising a non-mydriatic fundus photography screening programme. Secondary objectives include diagnostic accuracy among emergency physicians compared to telehealth ophthalmologist review. Methods: Prospective cross-sectional study investigating non-mydriatic fundus photography as a new diagnostic test in two tertiary Australian EDs. Consecutive adult patients were enrolled if they presented with headache, focal neurological deficit, visual disturbance or diastolic BP >120 mmHg. Diagnostic agreement was determined using kappa statistics and sensitivity and specificity using a reference standard consensus ophthalmology review. Results: A total of 345 consecutive patients were enrolled among whom 56 (16%, 95% confidence interval [CI] 13–21) had urgent fundus pathology. Agreement between emergency physician and ophthalmic assessment of fundus photographs was 74% (kappa = 0.196, P = 0.001). Emergency physicians had 40% sensitivity (95% CI 27–54) and 82% specificity (95% CI 76–86) for detecting urgent pathology on photographs. Conclusions: Fundus photography detects a clinically significant proportion of fundus pathology and urgent diagnoses. Telehealth specialist image review is important to detect some important, time-critical illnesses that can be missed in routine care. This offers an accurate alternative to direct ophthalmoscopy that warrants further research in Australian EDs.