Elsevier

Pediatric Neurology

Volume 83, June 2018, Pages 32-37
Pediatric Neurology

Original Article
Video Diversion Improves Success Rate of Fundoscopic Examination in Children: A Prospective Randomized Controlled Trial

https://doi.org/10.1016/j.pediatrneurol.2017.09.008Get rights and content

Abstract

Background

Fundoscopy is an important component of the neurological examination as it can detect pathologies such as high intracranial pressure. However, the examination can be challenging in young children. This study evaluated whether playing a video during eye examination improves the success, duration, and ease of pediatric fundoscopy.

Materials and Methods

This was a prospective, multipractitioner, multiclinic, randomized controlled trial. Patients aged one to four years were recruited in the emergency department, neurology clinic, spinal cord clinic, and general pediatric clinic. Eye examination was randomized to video or non–video-assisted fundoscopy. Successful examinations were defined as visualizing the fundus within 60 seconds. Time to visualize optic disc was recorded and difficulty of examination was assessed using a 10-point Likert scale.

Results

We recruited 101 subjects with a mean age of 2.8 years. Overall, there was a 20% absolute improvement in the success rate of visualizing the optic disc in the video versus non-video group (P < 0.001, 95%CI: 7.8% to 31%). Time to visualize optic disc was also improved (Δ5.3 seconds, P < 0.01, 95%CI: 1.4 to 9.1 seconds). Practitioners and caregivers noticed a 33% (P < 0.01, 95%CI: 21% to 44%) and 42% (P < 0.01, 95%CI: 30% to 56%) relative improvement in the ease of examination with video, respectively.

Conclusions

The use of videos improved the ease, duration, and, most importantly, the success of fundoscopy in younger children. This simple, inexpensive adjunct has great potential to improve the ease and efficacy of this aspect of the neurological examination and allow fundoscopic examination to be effectively performed earlier in the age-appropriate vision screening protocols.

Introduction

Neurological examination is one of the most difficult aspects of the physical examination, especially the fundoscopic examination.1, 2, 3, 4 The fundoscopic examination is an essential aspect of the neurological examination, especially in patients presenting with headache, altered mental status, trauma, or acute changes in visual acuity. It can detect conditions such as increased intracranial pressure and optic nerve atrophy. However, many clinicians would argue fundoscopic examination is especially difficult, if not impossible, in an uncooperative young child.4, 5, 6 Descriptions regarding the administration of fundoscopic examinations are readily available in the literature, including anecdotal strategies to improve the success rate of fundoscopic examination in children such as the “simultaneous mouth open technique.”7 More commonly, items able to draw the patient's attention such as a motorized animal or sound generating toys are used to help facilitate fundoscopic examination.8 However, simple approaches to improve success rates that are substantiated by scientific rigor are lacking. In uncooperative children who require visualization of the optic disc, current options include using general anesthetics or digital retinal nonmydriatic cameras. However, these options are expensive, invasive, and not easily accessible.9, 10, 11

To address this need, the authors previously conducted a single-practitioner proof-of-concept study which demonstrated that by simply playing a video of the patient's choice during fundoscopy, the success rate of visualizing the optic disc was improved by 28% in children age one to eight years.12 This previous study was limited by being a single practitioner study, which restricted the generalizability and adoptability in different clinical settings. This present study addresses the limitation by evaluating whether playing a video during fundoscopic examination improves the success, duration, and ease of pediatric fundoscopy in four different clinical settings involving different practitioners. The hypothesis is simple video diversion (e.g., using a handheld phone, tablet device, or computer) improves the success rate of direct fundoscopy, time to visualize optic-disc, as well as the ease from the practitioner and family perspective.

Section snippets

Trial design

An unblinded, prospective, multipractitioner, multiclinic randomized trial to assess the efficacy of video diversion in improving the success of fundoscopy in children age one to four years was performed. The trial was conducted in four different clinical settings, which included the emergency department, general pediatric clinic, spinal cord clinic, and pediatric neurology clinic. Patients were randomized (using a random number generator, www.random.org) by order of ocular examination (left to

Patient demographics

A total of 101 participants was recruited. The distribution of patients recruited in each clinical setting is outlined in Table 1. The average age of the participants was 2.8 years old (1.0 to 4.9 years), with a male to female ratio of 1.3:1. There were 62 patients from age one to two years and 39 patients from age 3 to 4 years. Of the 101 patients enrolled, 89 were examined by a staff physician, 10 by residents, and two by fellows. Of the patients examined by residents, five were performed in

Discussion

Fundoscopy has a well-deserved reputation for being a difficult aspect of the neurological examination, especially in young children.4, 13 Benbassat et al.14 emphasized the importance of fundoscopy to “recognize retinal signs of uncommon life-threatening diseases” such as papilledema and retinal hemorrhages. However, studies have reported underutilization of fundoscopy by nonophthalmologic physicians.14 Fundoscopy is inherently difficult to teach as there is no way to verify that the student

Conclusion

In conclusion, video diversion was successful at improving the success rate, ease, and time required to perform fundoscopy in children aged one to four years, in multiple clinical settings by practitioners of varying levels of experience. There was no effect on the success rate and time in older children, but ease of examination improved. This is the first study that has shown a method, which allows a high rate of fundoscopic success rate in patients aged one to two years. This simple,

Acknowledgments

We acknowledge Alexander Cheong BSc (University of British Columbia) for his assistance in calculating the CIs for this study.

References (17)

There are more references available in the full text version of this article.

Cited by (1)

  • Pediatric point-of-care ultrasound of optic disc elevation for increased intracranial pressure: A pilot study

    2021, American Journal of Emergency Medicine
    Citation Excerpt :

    Even when non-ophthalmologist clinicians do perform DO, they fail to detect most cases of papilledema [8,16,17,21], which can lead to high medicolegal costs due to poor ophthalmologic and neurologic outcomes from undiagnosed increased ICP [22,23]. Further barriers to DO in children include small pupillary diameters and lack of cooperation [24-27]. For decades, ophthalmologists have used ocular point-of-care ultrasound (POCUS) to assess the optic nerve, which has been adopted more recently by pediatricians [28,29], general and pediatric emergency physicians [30-36], obstetricians [37], neurosurgeons [38], and neurologists [39-42] to assess the optic nerve head for the optic disc elevation that accompanies all grades of papilledema [4].

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.

Conflicts of interest: The authors have no conflicts of interest to disclose.

Trial Registration: ClinicalTrials.gov: NCT02784132.

View full text
© 2017 Elsevier Inc. All rights reserved.