The Open Ophthalmology Journal




ISSN: 1874-3641 ― Volume 13, 2019

The Value of Fundoscopy in General Practice



Irini P Chatziralli*, 1, 2, Evgenia D Kanonidou 1, Petros Keryttopoulos 3, Prodromos Dimitriadis 3, Leonidas E Papazisis 1
1 Department of Ophthalmology, General Hospital of Veroia, Veroia, Greece
2 Eye Department, Barts and the London NHS Trust, London, UK
3 Department of Internal Medicine, General Hospital of Veroia, Veroia, Greece

Abstract

Background:

Many of the common systemic diseases present characteristic changes in the fundus of the eye, but fundoscopy is often performed by an ophthalmologist. Our purpose was to assess the value of fundoscopy for the general practitioners (GPs) regarding the diagnosis and management of the cases which they face in daily practice.

Methods:

689 patients were referred by GPs to the outpatient ophthalmology department for fundoscopy during the year 2010. The causes of this referral, the results of ophthalmoscopy and its significance in the final diagnosis were recorded and analyzed.

Results:

In 22 patients (3.1%), fundoscopy revealed optic disc edema. In 7 patients with head trauma (9.7%), fundoscopy revealed intravitreous haemorrhage and Berlin edema. From the patients with photopsias or floaters, 5 (10.2%) had retinal detachment. Finally, in cases with diabetes mellitus or hypertension, ophthalmoscopy was very important to detect the existence and grade the degree of diabetic or hypertensive retinopathy, if they appeared, and as a result to evaluate the prognosis of the disease.

Conclusions:

Fundoscopy is fundamental for the GP, as it may help to confirm or exclude the diagnosis of many common diseases. Nevertheless, there are clinical entities where ophthalmoscopy should be performed by an ophthalmologist, in order to be more specific and accurate, and GP should be able to recognise these cases.

Keywords: Fundoscopy, general practice, ophthalmoscopy.


Article Information


Identifiers and Pagination:

Year: 2012
Volume: 6
First Page: 4
Last Page: 5
Publisher Id: TOOPHTJ-6-4
DOI: 10.2174/1874364101206010004

Article History:

Received Date: 12/1/2012
Revision Received Date: 4/2/2012
Acceptance Date: 4/2/2012
Electronic publication date: 14/3/2012
Collection year: 2012

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 867
Abstract HTML Views: 693
PDF Downloads: 186
Total Views/Downloads: 1746

Unique Statistics:

Full-Text HTML Views: 464
Abstract HTML Views: 412
PDF Downloads: 144
Total Views/Downloads: 1020
Geographical View

© Chatziralli et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http: //creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the 28 Papanastasiou street, Agios Dimitrios, Athens, 17342, Greece; Tel: 00306973046326; Fax: 00302109312008; E-mails: eirchat@yahoo.gr, irini.chatziralli@bartsandthelondon.nhs.uk




INTRODUCTION

Many of the common systemic diseases present characteristic changes in the fundus of the eye. These changes can be observed before the clinical manifestations of the disease, which come at a later stage. Consequently, the value of fundoscopy has been well established and every medical doctor is expected to be able to use the ophthalmoscope [1 Gilkes MJ. The GP and the specialist ophthalmology Br Med J 1982; 285: 1247-8.-3 Ganguly AK. Scope of ophthalmoscopy in general practice and its significance Indian Med J 1964; 61: 39-41.]. However, in the majority of public hospitals, fundoscopy is performed by an ophthalmologist, even though it may concern cases of general practice. Under the light of the above, this study aims to assess the value of fundoscopy for the general practitioners (GPs) regarding the diagnosis and management of the cases which they face in daily practice.

MATERIALS AND METHODOLOGY

Participants in our study were 689 patients (297 male and 392 female), age range from 7 to 78 years old (median age 38 years old), who were referred by GPs to the Ophthalmology Outpatient Department at General Hospital of Veroia, Greece for fundoscopy during the year 2009. Specifically, from the total number of referred cases, 517 patients were referred by the emergency department due to headache (27.5%-142 of 517 patients), dizziness or vertigo (8.7%-45 of 517), fever of unknown origin (FUO) (32.7%-169 of 517), head trauma (13.9%-72 of 517), photopsias or floaters (9.4%-49 of 517), hypertension crisis (2.3%-12 of 517) and acute stroke (5.5%-28 of 517). 172 patients were also referred by the internal medicine department to investigate if their eyes were affected by diabetes mellitus (56.9%-98 of 172) or hypertension (43.1%-74 of 172). All patients underwent dilated fundoscopy by an ophthalmologist, using the indirect ophthalmoscope. The outcome of ophthalmoscopy was recorded in each case.

RESULTS

In 6 patients with headache (4.2%), the fundoscopy revealed edema of the optic disc caused by an endocranial tumor, as it was confirmed later by computerized tomography. Fundoscopy in all patients suffered from dizziness or vertigo was normal, as well as in those with hypertension crisis. In 9 patients with FUO (5.3%), ophthalmoscopy contributed to the diagnosis of a central nervous system (CNS) infection i.e., meningitis. Moreover, it was also necessary for the other patients with FUO, as it was considered mandatory before performing a lumbar puncture to evaluate the possibility of CNS infection. In 7 patients with head trauma (9.7%), fundoscopy revealed intravitreous haemorrhage and Berlin edema, while in 4 patients (5.6%) it showed signs of increased intracranial pressure due to subarachnoid haemorrhage. Increased intracranial pressure was also found in 3 patients with acute stroke (10.7%), in which papilloedema was observed in fundoscopy. From the patients with photopsias or floaters, 5 (10.2%) had retinal detachment, while 5 (10.2%) had retinal breaks. Finally, in cases with diabetes mellitus or hypertension, ophthalmoscopy was very important to detect the existence and grade of diabetic or hypertensive retinopathy, if they appeared, and as a result to evaluate the prognosis of the disease. It is also worthy to mention that in 8 from the total number of the 689 cases (1.2%) glaucoma has been first diagnosed by the damage of the optic nerve observed via fundoscopy.

DISCUSSION

Usually GPs and doctors of internal medicine refer patients to ophthalmologists to undergo fundoscopy either as an “emergency” case or in the context of a detailed systemic clinical examination. In “emergency” cases, the most frequent question is whether optic disc edema exists. Papilloedema is optic disc swelling secondary to increased intracranial pressure and its presence should raise the suspicion of serious intracranial pathology; ie. tumors, venous sinus thrombosis, subarachnoid haemorrage, CNS infection, haematoma or idiopathic intracranial hypertension. In these cases, ophthalmoscopy is a very important diagnostic tool in GP’s hands. Fundoscopy’s value is also significant in cases of head trauma, as it can reveal intracranial haemorrhages or causes of low vision (intravitreous haemorrhage). The GP should refer the patient to an expert doctor (neurosurgeon or ophthalmologist respectively) for further investigation and management of these cases.

Another special finding in fundoscopy is retinal or vitreous detachment, something difficult for a GP to diagnose with certainty. In these cases, the GP should be suspicious from the history of the patient and from the presented signs and symptoms, such as photopsias or floaters. If the GP is not sure about the diagnosis of retinal breaks or retinal detachment, it is better to refer the patient to an ophthalmologist, because this is an ocular emergency and may cause loss of vision, when treatment is not appropriate.

The fundus of the eye may reveal changes related to common diseases such as hypertension and diabetes mellitus [1 Gilkes MJ. The GP and the specialist ophthalmology Br Med J 1982; 285: 1247-8.-4 Griffith SP, Freeman WL, Shaw CJ, et al. Screening for diabetic retinopathy in a clinical setting: a comparison of direct ophthalmoscopy by primary care physicians with fundus photography J Fam Pract 1993; 37: 49-56.]. In a large percentage of patients with hypertension, sclerotic changes are primarily seen in the choroidal vessels and later exudation and flame shaped haemorrhages give the picture of hypertensive retinopathy. In addition to this, diabetic retinopathy usually appears in elderly people, having diabetes mellitus for 10 years or more and may be proliferative (neovascularization, vitrous haemorrhages or vitrous detachment) or non-proliferative (retinal microaneurysms, exudates, haemorrhages) [5 Gill JM, Cole DM, Lebowitz HM, Diamond JJ. Accuracy of screening for diabetic retinopathy by family physicians Ann Fam Med 2004; 2: 218-0.]. The GP should be able to recognise pathological changes in the fundus concerning the aforementioned diseases and if he finds something suspicious, he should always refer the patient to an ophthalmologist for a more specific and detailed ophthalmological examination, but not as an “emergency” case [5 Gill JM, Cole DM, Lebowitz HM, Diamond JJ. Accuracy of screening for diabetic retinopathy by family physicians Ann Fam Med 2004; 2: 218-0.].

It is worthy to mention that “unnecessary” referrals could be reduced by telemedicine, which uses the combination of telecommunication and information technologies to provide and support healthcare [6 Li HK. Telemedicine and ophthalmology Surv Ophthalmol 1999; 44: 61-72.]. As a part of telemedicine, teleophthalmology provides eye consultation by delivering high-quality eye images and videos over a public broadband network [7 Tang RA, Morales M, Ricur G, Schiffman JS. Telemedicine for eye care J Telemed Telecare 2005; 11: 391-6.]. In this way, GPs could have a database of retina images to compare with the image found in fundoscopy, so as to identify which case is really “urgent”. In addition, they could seek advice from an ophthalmologist by telemedicine program, therefore the ophthalmology outpatients’ department would not be burdened with “unnecessary” referrals.

CONCLUSION

The study demonstrates that fundoscopy is an essential skill for the GP and should not be underestimated, as it may be necessary to confirm or exclude the diagnosis of many common ocular or systemic diseases. However, there are clinical entities where ophthalmoscopy should be performed by an ophthalmologist, in order to obtain a more specific and accurate diagnosis, and the GP should be able to recognise these cases. Further examination of the eye with fundoscopy can assist the diagnosis of systemic disease. 

ACKNOWLEDGEMENT

None declared.

CONFLICT OF INTEREST

None declared.

REFERENCES

[1] Gilkes MJ. The GP and the specialist ophthalmology Br Med J 1982; 285: 1247-8.
[2] Gurland BB. The GP and the ophthalmoscope J Med Soc N J 1964; 61: 447-8.
[3] Ganguly AK. Scope of ophthalmoscopy in general practice and its significance Indian Med J 1964; 61: 39-41.
[4] Griffith SP, Freeman WL, Shaw CJ, et al. Screening for diabetic retinopathy in a clinical setting: a comparison of direct ophthalmoscopy by primary care physicians with fundus photography J Fam Pract 1993; 37: 49-56.
[5] Gill JM, Cole DM, Lebowitz HM, Diamond JJ. Accuracy of screening for diabetic retinopathy by family physicians Ann Fam Med 2004; 2: 218-0.
[6] Li HK. Telemedicine and ophthalmology Surv Ophthalmol 1999; 44: 61-72.
[7] Tang RA, Morales M, Ricur G, Schiffman JS. Telemedicine for eye care J Telemed Telecare 2005; 11: 391-6.

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open