Visual field, pupillary defects among risk factors linked to abnormal neuroimaging in ED
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Key takeaways:
- Visual field defects, afferent pupillary defects and abnormal optic discs were associated with positive neuroimaging findings.
- Among patients with neuro-ophthalmological complaints, 77.3% reported blurry vision.
Visual field irregularities, afferent pupillary defects or abnormal optical discs were associated with positive neuroimaging findings among patients presenting to the ED with neuro-ophthalmological complaints, according to a study.
“Neuro-ophthalmological emergencies are one of the most challenging presentations that require urgent evaluation and management to avoid vision or life-threatening sequelae,” researchers at the American University of Beirut wrote in Medicine. “The differential diagnosis is often broad, and the presenting chief complaints include eye pain, blurred vision, vision loss, diplopia, ptosis and positive visual phenomena (flashes, dots, lights, or colors). Hence, emergency physicians are often faced with the challenge and need for prompt imaging and consultations.”
In a retrospective, cross-sectional study of electronic medical records of patients presenting to the ED at American University of Beirut Medical Center between January 2012 and September 2019, researchers examined 211 cases involving neuro-ophthalmological complaints.
More than half of patients had unilateral eye complaints (53.6%), with blurry vision (77.3%) and headaches (42.2%) among the most commonly reported symptoms.
According to results, complaints of blurry vision or visual field changes were significantly associated with positive findings on neuroimaging, as was having a visual field defect, abnormal pupil reactivity, afferent pupillary defect or an abnormal optic disc examination upon presentation to the ED.
“These findings — when combined with the proper clinical setting — should lower the threshold to proceed with neuroimaging in the emergency department,” researchers wrote. “Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.”
Perspective
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This retrospective, cross-sectional study aims to guide emergency physicians to selectively perform neuroimaging when patients present with ocular complaints. The most common symptoms of these patients were blurred vision and headaches. Patients with both symptoms, and with the presence of visual field defects, abnormal pupil reactivity, abnormal optic disc exam or afferent pupillary defects were most likely to reveal positive findings on imaging. Of all ordered tests, only 15% of head computed tomography scans and 56% of magnetic resonance imaging revealed positive abnormal findings.
This study is relevant because these results indicate excessive testing may possibly be due to discomfort and inexperience in diagnosing neuro-ophthalmological conditions by the emergency team. The authors show tangible guidelines to avoid over-imaging and prevent time-consuming, resource-draining and often unnecessary radiation exposure. This study demonstrates the prevailing belief among practicing optometrists that a careful optometric exam, and knowing when to refer, is extremely valuable for avoiding negative outcomes regarding neuro-optometric emergencies. Shortcomings of this study include its retrospective nature and the patient demographic not being representative of all populations around the world.
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