The Role of Fundoscopy Before Lumbar Puncture in Children with Suspected Meningitis

Nir Friedman; Or Kaplan; Gidon Test; Jordanna H Koppel; Gal Altberg; Neta Cohen; Nitai Levy; Segev Gil-Ad; Naama Kuchinski Cohen; Nili Yanai Milshtein; Hagit Poran Feldman; Haitam Mreisat; Yulia Gimelraikh; Gal Kimhi; Liat Gelernter Yaniv; Ron Jacob

doi:10.1007/s00431-025-06603-w

The Role of Fundoscopy Before Lumbar Puncture in Children with Suspected Meningitis

Eur J Pediatr. 2025 Nov 14;184(12):759. doi: 10.1007/s00431-025-06603-w.

Authors

Nir Friedman^{1

2}, Or Kaplan^{3

4}, Gidon Test³, Jordanna H Koppel^{5

2}, Gal Altberg^{6

2}, Neta Cohen^{7

2}, Nitai Levy⁸, Segev Gil-Ad⁹, Naama Kuchinski Cohen¹⁰, Nili Yanai Milshtein¹¹, Hagit Poran Feldman^{12

13}, Haitam Mreisat^{14

15}, Yulia Gimelraikh¹⁶, Gal Kimhi^{17

2}, Liat Gelernter Yaniv^{18

19}, Ron Jacob^{20

21}

Affiliations

¹ Pediatric Emergency Department, Meir Medical Center, Kfar Saba, Israel.
² Gray Faculty of Medicine and Health Science, Tel Aviv University, Tel Aviv, Israel.
³ Pediatric Emergency Department, Saban Pediatric Medical Center, Soroka University Medical Center, Beer Sheva, Israel.
⁴ Faculty of Health Science, Ben Gurion University of the Negev, Beer Sheva, Israel.
⁵ Pediatric Emergency Department, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
⁶ Emergency Department, Schneider Children's Medical Center, Petah Tikva, Israel.
⁷ Pediatric Emergency Department, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
⁸ Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel.
⁹ Pediatric Emergency Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
¹⁰ Pediatric Emergency Unit, Hillel Yaffe Medical Center, Hadera, Israel.
¹¹ Pediatric Emergency Department, Samson Assuta University Hospital, Ashdod, Israel.
¹² Pediatric Emergency Department, Laniado Sanz Medical Center, Natania, Israel.
¹³ Adelson School of Medicine, Ariel University, Ramat HaSharon, Israel.
¹⁴ Pediatric Emergency Unit, The Tzafon Medical Center, Poriya, Israel.
¹⁵ Azrieli Faculty of Medicine, Bar Ilan University, Ramat Gan, Israel.
¹⁶ Pediatric Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel.
¹⁷ Pediatric Emergency Department, Mayanei Hayeshua Medical Center, Bnei Brak, Israel.
¹⁸ Pediatric Emergency Unit, Bnai-Zion Medical Center, Haifa, Israel.
¹⁹ The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel.
²⁰ Pediatric Emergency Department, Ha'Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel. ron.jacobb@technion.ac.il.
²¹ The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel. ron.jacobb@technion.ac.il.

Abstract

Purpose: To assess the diagnostic yield and clinical impact of fundoscopy before lumbar puncture (LP) in children with suspected meningitis.

Methods: A multicenter retrospective cohort study across 15 pediatric emergency departments, including children aged 18 months-18 years with suspected meningitis between July 2018 and June 2023. The primary outcome was papilledema prevalence; secondary outcomes were subsequent abnormal neuroimaging, LP deferral, and time to antibiotics.

Results: Among 1,742 children (median age 4.6 years), bacterial meningitis was confirmed in 56 (3.2%). Fundoscopy was performed by ophthalmology residents in 959 (55.1%). Papilledema was identified in 27 (2.8%); all underwent CT, which revealed no contraindications to LP, and all proceeded to LP. Three children with normal fundoscopy who underwent LP were later found to have CT abnormalities (brain abscess and tumor); none of which led to adverse outcomes. Antibiotics were administered before LP less often when fundoscopy was performed (42.6% vs 58.8%, p < 0.001), although median time to antibiotics was similar (341 vs 269 min, p = 0.52). Children who had a head CT without fundoscopy received antibiotics earlier (239 vs 341 min; p = 0.039), and more frequently before LP (64.3% vs 42.6%, p < 0.001).

Conclusions: Routine fundoscopy before LP rarely detected papilledema, did not identify contraindications to LP, and was associated with lower rates of early antibiotic treatment. These findings suggest that fundoscopy adds little to safe LP decision-making and may inadvertently delay care in time-critical meningitis. A selective, clinically guided pre-LP approach, rather than routine fundoscopy, could streamline evaluation and improve practice.

What is known: • Fundoscopy is often performed before lumbar puncture (LP) in children with suspected meningitis to detect papilledema and guide decision about neuroimaging. • Evidence for its diagnostic yield and clinical impact in pediatric emergency settings is limited.

What is new: • In a multicenter cohort of 1,742 children, fundoscopy (performed by ophthalmology residents) detected papilledema in only 2.8% of cases and revealed no contraindications to LP. • Fundoscopy was associated with lower rates of early antibiotic administration.

Keywords: Fundoscopy; Lumbar puncture; Meningitis; Pediatric emergency department.

Publication types

Multicenter Study

MeSH terms

Adolescent
Anti-Bacterial Agents / therapeutic use
Child
Child, Preschool
Emergency Service, Hospital
Female
Humans
Infant
Male
Meningitis, Bacterial* / complications
Meningitis, Bacterial* / diagnosis
Papilledema* / diagnosis
Papilledema* / epidemiology
Papilledema* / etiology
Retrospective Studies
Spinal Puncture* / methods
Tomography, X-Ray Computed

Substances

Anti-Bacterial Agents