Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study.
OBJECTIVE
Nonmydriatic fundus photography by non-ophthalmic-trained personnel has recently been shown to be a potential alternative to direct ophthalmoscopy in the emergency department (ED). We evaluated the reliability of a novel quality rating scale and applied this scale to nonmydriatic fundus photographs taken during routine ED patient encounters to determine factors associated with diminished photograph quality.


METHODS
Prospective, cross-sectional study.


METHODS
We included 350 patients enrolled in the Fundus photography versus Ophthalmoscopy Trials Outcomes in the Emergency Department study who were photographed by nurse practitioners after <30 minutes of training followed by supervision.


METHODS
Photographs of both eyes were graded for quality on 2 occasions by 2 neuro-ophthalmologists. Four regions were independently evaluated for quality: Optic disc, macula, and superior and inferior vascular arcades. Quality as a function of the number of photographs taken was evaluated by Kaplan-Meier analysis. Mixed effects ordinal logistic regression was used to evaluate for predictors of image quality while accounting for the repeated measures design.


METHODS
Overall photographic quality (1-5 scale; 5 best).


RESULTS
We evaluated 1734 photographs. Inter- and intraobserver agreements between neuro-ophthalmologists were very good (weighted kappa, 0.84-0.87). Quality of the optic disc area was better than those of other retinal areas (P<0.002). Kaplan-Meier analysis showed that if a high-quality photograph of an eye was not obtained by the third attempt, it was unlikely that one would be obtained at all. A 10-second increase in the interphotograph interval before a total of 40 seconds increased the odds of a 1-unit higher quality rating by 1.81 times (95% confidence interval [CI], 1.68-1.98), and a 10-year increase in age decreased the odds by 0.76 times (95% CI, 0.69-0.85). Black patients had 0.42 times (95% CI, 0.28-0.63) the odds of a 1-unit higher quality rating compared with whites.


CONCLUSIONS
Our 5-point scale is a reliable measure of nonmydriatic photograph quality. The region of interest, interphotograph interval, and patient age and race are significant predictors of image quality for nonmydriatic photographs taken by nurse practitioners in the ED. Addressing these factors may have a direct impact on the successful implementation of nonmydriatic fundus photography into the ED.
Department of Ophthalmology, Emory University, Atlanta, Georgia, USA.
Cédric
C
Lamirel
Beau B
BB
Bruce
David W
DW
Wright
Kevin P
KP
Delaney
Nancy J
NJ
Newman
Valérie
V
Biousse
D000328:Adult; D044383:Black People; D003430:Cross-Sectional Studies; D004632:Emergency Medical Services / Q000592:standards*; D005654:Fundus Oculi; D006801:Humans; D008875:Middle Aged; D009184:Mydriatics / Q000008:administration & dosage; D009722:Nurse Practitioners / Q000592:standards*; D015588:Observer Variation; D009885:Ophthalmology / Q000592:standards; D009887:Ophthalmoscopy / Q000379:methods; D010781:Photography / Q000592:standards*; D011446:Prospective Studies; D011680:Pupil / Q000187:drug effects; D019984:Quality Indicators, Health Care / Q000592:standards*; D015203:Reproducibility of Results; D012164:Retinal Diseases / Q000175:diagnosis* / Q000208:ethnology; D015351:Vision Screening / Q000295:instrumentation / Q000592:standards; D044465:White People
D009184:Mydriatics