Yield and clinical efficacy of funduscopic examinations performed in the pediatric emergency room

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.