Fundoscopy use in neurology departments and the utility of smartphone photography: a prospective prevalence and crossover diagnostic accuracy study amongst neurology inpatients.

BACKGROUND AND PURPOSE: Although fundoscopy is a crucial part of the neurological examination, it is challenging, under-utilized and unreliably performed. The aim was to determine the prevalence of fundus pathology amongst neurology inpatients and the diagnostic accuracy of current fundoscopy practice compared with systematic screening with smartphone fundoscopy (SF) and portable non-mydriatic fundus photography (NMFP). METHODS: This was a prospective cross-sectional surveillance and diagnostic accuracy study on adult patients admitted under neurology in an Australian hospital. Inpatients were randomized to initial NMFP (RetinaVue 100, Welch Allyn) or SF (D-EYE) followed by a crossover to the alternative modality. Images were graded by neurology doctors, using telemedicine consensus neuro-ophthalmology NMFP grading as the reference standard. Feasibility parameters included ease, comfort and speed. RESULTS: Of 79 enrolled patients, 14.1% had neurologically relevant pathology (seven, disc pallor; one, hypertensive retinopathy; three, disc swelling). The neurology team performed direct ophthalmoscopy in 6.6% of cases and missed all abnormalities. SF had a sensitivity of 30%-40% compared with NMFP (45.5%); however, it had a lower rate of screening failure (1% vs. 13%, p < 0.001), a shorter examination time (1.10 vs. 2.25 min, p < 0.001) and a slightly higher patient comfort rating (9.2 vs. 8/10, p < 0.001). CONCLUSION: Our study demonstrates a clinically significant prevalence of fundus pathology amongst neurology inpatients which was missed by current fundoscopy practices. Portable NMFP screening appears more accurate than SF, whilst both are diagnostically superior to routine fundoscopic practice, feasible and well tolerated by patients.

Primary Extradural Ectopic Orbital Meningioma in a Child.

The authors describe a rare case of primary extradural ectopic meningioma of the orbit in a 13-year-old female managed with surgical excision, adding to the very limited literature of this diagnosis in children. This is the second case to show a radiological abnormality in the gyrus rectus and olfactory bulb; however, in our case, there was no radiological evidence of connection seen.

Assessment of Saccadic Velocity at the Bedside.

Saccades are a key component for the assessment and diagnosis of Neuro-ophthalmological disorders. Traditionally, clinicians have been taught to use large amplitude saccades (LAS) to assess saccadic velocity (SV), when small amplitude saccades (SAS) may be more effective. This study aimed to evaluate the advantages of SAS over LAS by presenting a video to 108 clinicians where both methods were used to assess a patient with a unilateral partial 6th nerve palsy. SAS was the preferred method in identifying the 6th nerve palsy by 43/55 (78.2%) of Neurologists, and 36/53 (67.9%) of Ophthalmologists. These findings indicate that SAS may be a more effective method than LAS for determining SV.

Complete Inferior Rectus Transection Following Blunt Trauma: A Case Report and Novel Approach to Surgical Repair.

Inferior rectus avulsion following blunt trauma is rare, with even fewer reported cases of complete transection. The authors report a case of orbital floor fracture and inferior rectus muscle transection without herniation following blunt orbital trauma. This case first highlights the difficulty in diagnosing complete inferior rectus muscle transection clinically and with imaging and second that an acceptable functional outcome can be achieved by a novel surgical repair approach utilizing contiguous orbital anatomical relations of the inferior oblique and inferior rectus muscles.

Long-term Ergotamine Derivative Therapy for Migraine Associated with Pachymeningitis and Sixth Cranial Nerve Palsy.

Chronic use of ergotamine derivatives has been well described in the literature to cause retroperitoneal, pleural, pericardial and valvular fibrosis. While acute migraine treatment advances have resulted in a reduction of ergotamine derivatives prescribing, they are still considered appropriate for some patients. We report a case of diffuse pachymeningitis with symptomatic right sixth cranial nerve palsy who had a history of long-term Cafergot© suppository use. To the best of our knowledge, this is the first case to temporally associate ergotamine derivatives with pachymeningitis.

The Aortic Isthmus: A Significant yet Underexplored Watershed of the Fetal Circulation.

The aortic isthmus (AoI) is a unique fetal watershed with a waveform reflecting its complex haemodynamic physiology. The systolic component represents left and right ventricular systolic ejection, and the diastolic component represents comparative downstream vascular impedance between the brachiocephalic and subdiaphragmatic fetal circulations. Several indices have been devised to quantify different components of the waveform, including the pulsatility index, resistance index, isthmic flow index, and recently the isthmic systolic index. There have been promising preliminary studies applying these indices to both cardiac (congenital) and extracardiac pathologies, including intrauterine growth restriction and twin-twin transfusion syndrome. However, the waveform's multifactorial origin has proven to be challenging, and the difficulty in separating various components of the waveform could explain that AoI evaluation does not have a clear clinical utility. Further research is underway to realise the full potential of this vessel in fetal cardiac and haemodynamically compromised pathological conditions. In this review article we outline the physiological origin of this Doppler waveform, describe in detail the various published indices, summarise the published literature to date, and finally outline potential future research and hopefully clinical applications.