Using non-mydriatic fundus photography to detect fundus pathology in Australian metropolitan emergency departments: A prospective prevalence and diagnostic accuracy study

Emerg Med Australas. 2021 Apr;33(2):302-309. doi: 10.1111/1742-6723.13619. Epub 2020 Sep 17.


Objective: To determine the prevalence of fundus pathology in metropolitan Australian EDs utilising a non-mydriatic fundus photography screening programme. Secondary objectives include diagnostic accuracy among emergency physicians compared to telehealth ophthalmologist review.

Methods: Prospective cross-sectional study investigating non-mydriatic fundus photography as a new diagnostic test in two tertiary Australian EDs. Consecutive adult patients were enrolled if they presented with headache, focal neurological deficit, visual disturbance or diastolic BP >120 mmHg. Diagnostic agreement was determined using kappa statistics and sensitivity and specificity using a reference standard consensus ophthalmology review.

Results: A total of 345 consecutive patients were enrolled among whom 56 (16%, 95% confidence interval [CI] 13-21) had urgent fundus pathology. Agreement between emergency physician and ophthalmic assessment of fundus photographs was 74% (kappa = 0.196, P = 0.001). Emergency physicians had 40% sensitivity (95% CI 27-54) and 82% specificity (95% CI 76-86) for detecting urgent pathology on photographs.

Conclusions: Fundus photography detects a clinically significant proportion of fundus pathology and urgent diagnoses. Telehealth specialist image review is important to detect some important, time-critical illnesses that can be missed in routine care. This offers an accurate alternative to direct ophthalmoscopy that warrants further research in Australian EDs.

Keywords: fundus oculi; headache; neurology; physical examination; telemedicine.

MeSH terms

  • Adult
  • Australia / epidemiology
  • Cross-Sectional Studies
  • Diagnostic Tests, Routine*
  • Emergency Service, Hospital
  • Humans
  • Mydriatics*
  • Photography
  • Prevalence
  • Prospective Studies
  • Sensitivity and Specificity


  • Mydriatics