Fundus anomalies: what the pediatrician’s eye can’t see
Department of Ophthalmology and the1 Pediatric Emergency Medicine Unit, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
Background. With increasing workloads for hospital doctors, routine funduscopy may be abandoned. It is not known how often pediatricians perform funduscopy and how skilled they are in performing it.
Objectives. To assess hospital pediatricians’ ability to diagnose abnormalities of the ocular fundi and to determine whether a short tutorial can improve their skills.
Methods. Physicians working at the pediatric division of a university-affiliated hospital participated in the study. All participants completed an anonymous questionnaire regarding their experience and skills in performing funduscopy. A pictorial quiz containing 20 fundus pictures of common findings in children was given. After completing the quiz, a 45-minute tutorial on common fundus anomalies was given. At the end of the lecture, the same quiz was given again. The percentage of correct answers for each quiz was scored.
Results. Sixteen physicians completed the study (11 pediatric residents and five senior pediatricians). Most participants did not feel competent at performing a fundus examination [mean score on a visual analog scale 1.96; range 0 (not competent at all) to 7]. The mean score for the fundus pictures quiz given before the tutorial was 48% (range 37–58%). The average score of the residents (47%) did not differ significantly from that of the senior pediatricians (42%). After the tutorial the mean grade increased significantly to 60% (P = 0.002). This was true both for residents (63%; P = 0.001) and seniors (55%; P = 0.004).
Conclusions. Our study shows that funduscopy is being neglected by pediatricians. Even a short tutorial may significantly improve the diagnostic value of this test.
Keywords: fundus oculi, pediatrics, physical examination
Address reprint requests to Yair Morad, Department of Ophthalmology, Assaf Harofeh Medical Center, Zerifin 70300, Israel. E-mail: ymorad{at}013.net.il
Accepted for publication May 9, 2004.
Examination of the ocular fundus has traditionally been considered an integral part of the physical examination of a child [1]. Life-threatening conditions such as raised intracranial pressure, miliary tuberculosis, and cytomegalovirus (CMV) infection may be revealed by ophthalmoscopy. Fundus examination may lead to the diagnosis of conditions such as glaucoma, shaken baby syndrome, and retinal detachment. Inspection of the ocular fundus may also help in the management of a number of systemic disorders, e.g. diabetes mellitus and systemic lupus erythematosus [2].
With increasing workloads for hospital doctors, routine funduscopy may be abandoned. It is not known how often pediatricians perform funduscopies or how skilled they are in performing them. This study assesses the views of hospital pediatricians on funduscopy, and their ability to examine the ocular fundi and diagnose abnormalities. In addition, pediatrician skills in detecting common fundus abnormalities were examined using a pictorial quiz and by determining the impact of a formal lecture on those skills.
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Physicians working at the pediatric division of a university-affiliated hospital (Assaf Harofeh Medical Center, Zrifin, Israel) participated in the study. All participants completed an anonymous questionnaire in which they described their exposure to formal teaching in ophthalmology, and assessed, using a visual analog scale, their ability to perform and interpret an ocular fundus examination accurately. They also estimated how often they perform the test and gave details regarding the technique. After completing the questionnaire, a pictorial quiz containing 20 fundus pictures was given. (The quiz can be found in International Journal for Quality in Health Care on-line as supplementary data.) Participants were asked to mark the correct diagnosis out of four possible options. Conditions presented in the quiz were: normal fundus; papilledema; retinal hemorrhages in shaken baby syndrome; optic atrophy; optic nerve hypoplasia; cytomegalovirus retinitis; glaucomatous optic nerve cupping; toxoplasomosis; retinoblasoma; and optic nerve pit. The first author, an experienced pediatric ophthalmologist, chose pictures of these conditions. The diagnoses most frequently encountered by pediatricians, such as papilledema, retinal hemorrhages from shaken baby syndrome, glaucoma, and also normal fundus, were presented more than once. After completing the quiz, a 45-minute tutorial on common fundus anomalies was given by the first author. None of the pictures presented in the quiz were shown during the tutorial. At the end of the lecture, the same quiz was given again. The percentage of correct answers for each quiz was scored. We used the Mann–Whitney test for comparison of non-parametric data and the Student’s t-test for parametric data. To compare the results before and after the tutorial, a matched-pairs Wilcoxon test was performed on sets of several pictures (e.g. pailledema), and McNemar’s test on single pictures (e.g. CMV).
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Sixteen physicians completed the study: 11 pediatric residents and five senior pediatricians. All the participants, except one, had graduated from one of the four medical schools in Israel. All the residents included in this study were from the same 5-year residency program, and graduated from medical school 2–10 years before the study (mean 4.5 years). The seniors had practiced pediatrics for 7–25 years (mean 17 years).
When asked about past exposure to formal teaching in ophthalmology, nine stated that they had attended a 2-week clinical course in an ophthalmology department during their clinical rotations as medical students, six had completed a formal teaching course without clinical practice, and one had received no exposure to ophthalmology at all. None of them elected to do a 1 month elective rotation in an ophthalmology department during their rotating internship (a rotating internship is mandatory in order to enter a residency program).
When asked to score their competency in performing a fundus examination on a visual analog scale, with 0 being entirely not competent in performing a fundus examination and 10 being fully competent, the median score was 1 (range 0–7). Residents were slightly more confident in their ability (median 1) than seniors (median 0.5); however, this difference did not reach statistical significance (P = 0.4, Mann–Whitney test). Six of the 11 residents (54.5%) and four out of five seniors (80%) selected a score of 0–1, meaning ‘not competent’ or ‘almost not competent’ in performing a fundus examination. When asked when they last performed a fundus examination, eight of 11 residents chose ‘during the last month’ or ‘during the last 3 months’; however, four of five seniors chose ‘never’ or ‘a year to 3 years ago’. When asked how many times they had actually examined a fundus during the last 12 months, nine of 11 residents and one of five seniors selected ‘one to three times only’, and the rest of the group selected ‘never’. All participants knew which dilating drops should be used in order to facilitate the examination; however, only four (three residents and one senior) ever actually used dilating drops before attempting the examination.
The mean score of the fundus pictures quiz given before the tutorial was 48% (range 37–58%). The average score of the residents (47%) was not significantly different to that of the senior pediatricians (42%). After the tutorial, the mean grade increased significantly to 60% (P = 0.002). This was true both for residents (63%; P = 0.001) and seniors (55%; P = 0.004).
Table 1 presents the conditions presented and the scores achieved before and after the tutorial. Before the tutorial, the only diagnoses that were recognized by >50% of the participants were retinoblastoma (88%) and papilledema (63%). After the lecture, normal fundus (70%), shaken baby syndrome (65%), and optic atrophy (88%) were also widely recognized.
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Our study results indicate that in a hospital setting in Israel, most pediatricians rarely examine the fundus themselves, and that most of them are not skilled enough in identifying life-threatening conditions.
Examination of the ocular fundus is an important part of the pediatric physical examination. It can help in diagnosing life-threatening conditions such as shaken baby syndrome or increased intracranial pressure, and help in monitoring chronic diseases such as diabetes. Although the art of performing this examination is taught at medical schools, it is more and more neglected throughout the years of clinical practice until seniors feel less competent in performing it than young residents. These results are supported by previous studies. Roberts et al. [3] distributed a similar questionnaire to 41 general practitioners working in the UK. The questionnaire was not validated. Sixty-six percent of respondents did not feel confident with their skills in performing a fundus examination. Eighty-three percent felt they would benefit from more training, 73% stated that they had insufficient training in funduscopy, and almost all (97%) believed their funduscopy skills could be improved. Reviewing the charts of 100 patients treated by those physicians disclosed that only three had a fundus examination reported. Similar results were reported from a survey done in Australia [4].
Our study shows that before refreshing their knowledge with a lecture, a large proportion of the pediatricians could not recognize life-threatening conditions such as papilledema and retinal hemorrhages, and 50% could not identify a normal fundus. Following a short lecture, the percentage of correct diagnosis of normal fundus rose further to 70%. For correct diagnosis of shaken baby syndrome, the percentage rose from 45% to 65% based on the fundus picture alone. These results are still far from satisfactory.
The diagnosis of retinal hemorrhages in shaken baby syndrome carries a heavy load of medical, ethical, and legal implications. Our study suggests that this diagnosis should not be left to the pediatrician since almost half of them misdiagnosed retinal hemorrhages. In a study [5] performed by one of the authors (Y.M.) at the Hospital for Sick Children, Toronto, Canada, the ability of non-ophthalmologists to diagnose retinal hemorrhages accurately was examined. Non-ophthalmologists did not attempt to (36%) or were ‘unable to examine’ (19%) the fundus in 72 children with shaken baby syndrome. In 13% of cases, retinal hemorrhages were missed when the fundus was examined. Our study confirms these results and also its conclusion that in cases such as suspected child abuse, ophthalmology consultation should be called for and the pediatrician’s evaluation of the fundus should be labeled as ‘primary inspection’ only.
Fundus examination is required daily in pediatric emergency departments as well as in pediatric wards and outpatient clinics. Sending all children who need a fundus examination to an ophthalmology consultation places a heavy burden on ophthalmologists, and causes inconvenience to the patients. It can also delay important examinations such as lumbar puncture, which is not performed before ruling out increased intracranial pressure. Enhancing the pediatrician’s skills in performing an accurate fundus examination may improve the medical care given to such patients.
The need for continuous medical education concerning funduscopy was previously stressed by Jackson et al. [4], who gave a course on how to perform a funduscopy to general practitioners in Australia, and by Codeiro and colleagues [6] who examined the effect an ophthalmoscopy course had on medical students’ funduscopy skills. In the current study, the ability of pediatricians to identify fundus abnormalities increased significantly following a 45-minute tutorial. It is reasonable to assume that a formal course could improve their skills further.
None of the pediatricians in our study reported the routine use of pupil-dilating drugs for fundus examination. Fundus examination of a child using a direct ophthalmoscope is not easy when the child is non-cooperative and scared. Trying to view the fundus through a narrow pupil sometimes makes this practically impossible. Yet, in our study, as well as in others, non-ophthalmologists rarely use dilating drops. Ophthalmologists, on the other hand, almost always use these drugs despite being much more competent in performing the examination [3,5]. Our study shows that the reason for that is not because pediatricians do not know which drugs to use. In many cases they actually prescribe these drugs to patients who are awaiting a fundus examination by an ophthalmologist. We believe that the reason pediatricians do not use dilating drugs is because they do not feel competent in performing the test, and view their examination only as a primary inspection before a formal ophthalmology consultation.
The current study has several limitations. The study group was small and all the participants were practicing in the same hospital. It is not known whether these results reflect the situation in Israel alone or in other countries too. Because of the small number of participants we could not compare the results of residents with those of senior pediatricians. One of the difficulties in performing a fundus examination in children is visualizing the optic disk. The current study did not address this issue. Since we used the same quiz before and after the tutorial, it is possible that part of the improvement we saw is because of the repeated exposure to the same images.
In conclusion, our study shows that funduscopy is being neglected by the common pediatrician. Every skill that is not practiced is lost. The same, sadly, is true for funduscopy. Although medical schools provide a proper foundation upon which such a skill can be mastered, lack of practice renders it a forgotten art. Even a short lecture significantly improved the diagnostic value of this test, and certainly more practice would make it even better.
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References |
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- Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians. Pediatrics 2003; 111: 902–907.
[Abstract/Free Full Text] - Sit M, Levin AV. Direct ophthalmoscopy in pediatric emergency care. Pediatr Emerg Care 2001; 17: 199–204 (quiz pp. 205–207).[CrossRef][Web of Science][Medline]
- Roberts E, Morgan R, King D, Clerkin L. Funduscopy: a forgotten art? Postgrad Med J 1999; 75: 282–284.
[Abstract/Free Full Text] - Jackson C, de Jong I, Glasson W. Royal Australian College of Ophthalmologists and Royal Australian College of General Practitioners National GP Eye Skills Workshops: colleges and divisions reskilling general practice. Clin Experiment Ophthalmol 2000; 28: 347–349.[CrossRef][Web of Science][Medline]
- Morad Y, Kim YM, Mian M, Huyer D, Capra L, Levin AV. Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. J Pediatr 2003; 142: 431–434.[CrossRef][Web of Science][Medline]
- Cordeiro MF, Jolly BC, Dacre JE. The effect of formal instruction in ophthalmoscopy on medical student performance. Med Teach 1993; 15: 321–325.[Web of Science][Medline]
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