Does Direct Ophthalmoscopy Have a Role in the Modern Nhs?

Matthew Hartley FY2 North Yorkshire and East Coast Foundation School

DOES DIRECT OPHTHALMOSCOPY HAVE A ROLE IN THE MODERN NHS?

“Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room. See, and then reason and compare and control,” William Osler told his students.[1] “But see first.”

Introduction

The direct ophthalmoscope was developed by a young German named Hermann Von Helmholtz in 1851. Credit must be given to the British “father of modern computing”, Charles Babbage, who first explored the concept of looking into the eye over four years earlier.[2] However, being unable to obtain an image upon demonstration of his instrument, it was in fact Helmholtz who became the first person to observe a living human fundus.[3] Known at the time as an “Augenspiegel” (eye-mirror), it would revolutionise ophthalmology. Prior to its invention, there was much speculation surrounding fundal physiology with some theories suggesting a process similar to that which makes fireflies glow was taking place. This relatively simple invention inspired a golden age of ophthalmology in the mid-nineteenth century, revealing a wealth of previously unseen medical signs we are familiar with today, such as papilloedema, disc atrophy and the cherry red spot associated with central retinal artery occlusion. From its early prototypes in Helmholtz’s workshop to the modern day, the basic principles of the ophthalmoscope have not changed. What has changed, however, is its usefulness and role in clinical medicine.

Many say ophthalmoscopy is a dying art, with physicians and medical students alike lacking confidence in its use.[4] It is a skill that is difficult to master and requires considerable hours of practise. There have also been huge technological advancements across all specialties, with computers and machinery replacing human skills which were at one time fundamental to practice. Ophthalmology is no exception, with alternatives to direct ophthalmoscopy such as fundus photography arguably deeming the skill redundant. Hence, does it still have a key role in the modern NHS, an arguably stretched healthcare system which is heavily reliant on cost-effective but good quality care? This essay aims to explore this by looking at three main themes: fundus photography as an alternative to direct ophthalmoscopy, cost-effectiveness, and the role of ophthalmoscopy in medical education.

Fundus Photography

Fundus photography uses a specialised microscope and camera equipment to take wide angle, high-quality pictures of the retina, entire optic disc and macula.[5] The idea has been around since Helmholtz was tinkering with his augenspiegel, but only recently has its full potential been recognised.3 It has been shown to be sensitive and specific in the detection and diagnosis of ophthalmic disease, importantly without the need for mydratics or extensive training and practise.5 Additionally, in an ever digitalising world and NHS, fundal photography makes sense. It is especially useful in monitoring chronic disease such as diabetic retinopathy, where serial images can be recorded and compared on screen at the click of a button. Despite its advantages compared to the direct ophthalmoscope, the angle of view of fundus photography is trumped by the 15x magnification of the direct ophthalmoscope, allowing detection of more subtle signs (Figure 2). Moreover, direct ophthalmoscopy can examine dynamic phenomena such as venous pulsations, which would not be seen on a static photograph.4 Comparison of the advantages and disadvantages of both methods are summarised below (Figure 3), although it is important to consider these not in isolation but relative to other compounding factors such as cost-effectiveness and education.

Figure 3: Table of comparison of direct ophthalmoscopy vs. fundus photography.
Direct ophthalmoscopy / Fundal photography
Angle-of-view in degrees5 / 5° / 45-140°
Availability / Common / Uncommon
Portability / Easily portable / Static
Cost[6] / ~£500 / ~£10,000 + maintenance
Training / Considerable / Minimal
Digitalised imaging / No / Yes
Dynamic clinical phenomena / Yes / No
Detection of diabetic eye disease[7] / 65% / 89%
Mydratic needed / Yes / No

Cost-effectiveness

In 1948 the National Health Service was born out of a long-held ideal that quality healthcare should be available to all. Directly funded by taxation, it relies on cost-effective medical practice and robust economic management.[8] Considering that the NHS is under more pressure than ever with an aging population, recruitment crises and euro-political uncertainty[9], could fundus photography as common practice be justified?

One study by Khan et al. screened 14,541 patients for diabetic retinopathy using fundus photography in a primary care setting in South Africa.[10] The cost to screen one patient was a mere $22. They extrapolated this data to a nationwide level and concluded that fundus photography would be cost-effective in a primary care setting, resulting in major long-term savings. Whilst it must be noted these findings are limited to a different healthcare system and only focuses on diabetic screening in primary care, the conclusions are still significant. Diabetes and its complications have been approximated to take up 10% of the entire £116.4 billion NHS budget for 2015-16,[11] and Public Health England has recognised the importance of fundus photography in diabetic screening.[12] With a 5% growth per annum in the number of patients diagnosed with diabetes in the UK, direct ophthalmoscopy is not a sustainable solution to screen this ever-expanding patient group.

Education and Training

Ophthalmoscopy has been performed as part of a routine physical or detailed ophthalmic exam for over a century, and can swiftly yield a number of important signs before one can say “Hermann Von Helmholtz”. Whilst healthcare professionals recognise its place in detecting ophthalmic disease, its use is often overlooked investigating severe hypertension, suspected raised intracranial pressure and cerebrovascular accidents.[13] As such, it has been shown to be of particular value in headache assessment.[14] Whatever its indication, the ophthalmoscope can detect valuable signs, when used correctly. This is important: due to the inherent technical difficulty in using an ophthalmoscope, it can be challenging to detect pathology if not used correctly.

Medical schools of today devote little of their syllabus to ophthalmology and therefore ophthalmoscopy. Indeed, in 2011 a clinical placement in ophthalmology was not even a requirement in all UK schools and even in those where it was compulsory, an average of only 7.6 days was dedicated to the speciality.[15] In an attempt to combat this, numerous teaching methods have been trialled to hone in on medical students’ skills, such as ophthalmoscopy simulation, online tutorials and fundus photography analysis. Several teaching trials have shown beneficial outcomes to students’ ability in using the direct ophthalmoscope.[16] Interestingly however, the TOTeMS Study in 2013 showed that medical students still preferred and were more accurate analysing fundus photographs in comparison to patient directed or simulated ophthalmoscopy.[17]

Let us reconsider the common complaint of headache. Direct ophthalmoscopy has always been an essential part of the workup in these patients, being able to detect signs of sinister causes such as optic disc pallor and papilloedema associated with raised intracranial pressure. To highlight the importance of fundus examination, Thulasi et al. studied patients presenting to accident and emergency with headache who were investigated with both fundus photography and neuroimaging.14 Of the patients who had abnormal fundi on fundus photography, fourteen out of thirty four (41%) had normal neuroimaging. This shows that fundus examination can detect serious disease that radiological studies (that we so often rely on) may miss. Although studies have evaluated the feasibility of fundus photography in A&E and concluded that it potentially could replace ophthalmoscopy,[18] fundus photography is still not widely available. In these hospitals, therefore, direct ophthalmoscopy must not only suffice, but be used with absolute competence to ensure the best outcome for the patient.

Conclusion

Having considered the use of the direct ophthalmoscope, the decline of its proficiency in clinical practice, its role in medical education and an arguably more effective alternative, should its place in the modern NHS be preserved at all?

One could argue that the most important role of the ophthalmoscope within the modern NHS is its use in medical education. Medical history tells us many practices have become redundant with newer, cheaper or more efficient techniques, such as ultrasound replacing Pinard’s stethoscope to examine the foetal heartbeat.1 Indeed, fundus photography has numerous benefits, but the theory and understanding of the principle of fundus examination lies with the direct ophthalmoscope. Not only this, but the ophthalmoscope requires the doctor to see the patient by the bedside, which is central to medical education. The context of a patient’s history and examination should always be considered before retiring behind a computer screen to study fundal photographs. For this reason, medical students must continue to learn and practise the direct ophthalmoscope examination.

Research has shown proficiency with direct ophthalmoscopes, as with many skills, decreases without regular reinforcement.[19] Modern medical school curricula, using intuitive and creative teaching methods, must emphasise its importance. Finally, in the current economic climate, fundus photograph cameras are not commonplace in the NHS, regardless of whether they can be proven to be cost-effective or not. So for now, the trusty augenspiegel may be your most useful tool at 2am in A&E when Mrs Smith has a severe headache.

[1]References

Porter R. Blood and guts – a short history of medicine. London, United Kingdom: The Penguin Group; 2003. p. 43, 119

[2] Charles Babbage Institute. Who was Charles Babbage? University of Minnesota [internet]. 2016 [cited 30 September 2016]. Available from: http://www.cbi.umn.edu/about/babbage.html

[3] Keeler CR. A brief history of the ophthalmoscope. Royal College of Ophthalmology [internet]. 2003 [cited 15 September 2016]. Available from: http://www.college-optometrists.org/filemanager/root/site_assets/oip/4-2/a_brief_history_of_the_ophthalmoscope.pdf

[4] Mackay DD, Garza PS, Bruce BB, Newman NJ and Biousse V. The demise of direct ophthalmoscopy – a modern clinical challenge. Neurol Clin Pract [internet] 2015 [cited 02 September 2016]; 5(2): pp. 150–157.doi:10.1212/CPJ.0000000000000115

[5] Ophthalmic Photographers Society. Fundus Photography Overview. [internet]. 2016 [cited 24 September 2016]. Available from: http://www.opsweb.org/?page=fundusphotography

[6] Optical Marketplace. Cost of ophthalmic equipment. [internet]. 2016 [cited 22 September 2016]. Available from: http://www.opticalmarketplace.co.uk/new-equipment/optical-equipment/ophthalmoscopes/

[7] Harding SP, Broadbent DM, Neoh C, White MC and Vora J. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study. BMJ [internet]. 1995 [cited 10 September 2016]; 28; 311(7013): pp. 1131–1135.

[8] NHS Choices. About the NHS. [internet]. 2016 [cited 26 September 2016] Available from: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx

[9] McKee M. Brexit: A confused concept that threatens public health. J Public Health (Oxf) [internet]. 2016 [cited 27 September 2016];38(1):pp. 3-5 doi:10.1093/pubmed/fdv205

[10] Khan T, Bertram MY,Jina R,Mash B,Levitt N and Hofman K. Preventing diabetes blindness: cost effectiveness of a screening programme using digital nonmydriatic fundus photography for diabetic retinopathy in a primary healthcare setting in South Africa. Diabetes Res Clin Pract [internet]. 2013 [cited 27 September 2016]; 101(2): pp. 170-6. doi: 10.1016/j.diabres.2013.05.006

[11] Diabetes.co.uk. The Cost of Diabetes. [internet]. 2016 [cited 06 October 016]. Available from: http://www.diabetes.co.uk/cost-of-diabetes.html

[12] Department of Health. Public Health Functions agreement 2015-16 no. 22 – NHS Diabetic screening programme. Page 16, Section 2.6. [internet]. 2016 [cited 11 September 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/383196/1516_No22_NHS_Diabetic_Eye_Screening_Programme_FINAL.pdf

[13] Wang JJ, Baker ML,Hand PJ,Hankey GJ,Lindley RI,Rochtchina E et al. Transient ischaemic attack and acute ischaemic stroke: associations with retinal microvascular signs. Stroke, a Journal of Cerebral Circulation [internet]. 2011 [cited 15 September 2016]; 42(2): pp. 404-8. doi: 10.1161/STROKEAHA.110.598599

[14] Thulasi P,Fraser CL,Biousse V,Wright DW,Newman NJand Bruce BB. Nonmydriatic ocular fundus photography amongst headaches patients in an emergency department. Neurology [internet]. 2013 [cited 22 September 2016]; 80(5): pp. 432-7. doi: 10.1212/WNL.0b013e31827f0f20

[15] Baylis O, Murray PL and Dayan M. Undergraduate ophthalmology education - A survey of UK medical schools. Medical Teacher [internet]. 2011 [cited 04 October 2016]; 33(6):pp. 468-71. doi: 10.3109/0142159X.2010.540594

[16] Mackay DD, Garza PS, Bruce BB, Newman NJ and Biousse V. Selected direct ophthalmoscopy studies in medical students published between 2004 – 2014. Neurology in Clinical Practise [internet]. 2015 [cited 02 September 2016]; 5(2): pp.150–157 doi:10.1212/CPJ.0000000000000115

[17] Kelly LP, Garza PS,Bruce BB,Graubart EB,Newman NJand Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS study). Am J of Ophthalmol [internet]. 2013 [cited 04 September 2016]; 156(5): pp. 1056-1061.e10. doi: 10.1016/j.ajo.2013.06.022

[18] Bruce BB, Lamirel C,Biousse V,Ward A,Heilpern KL,Newman NJet al. Feasibility of nonmydriatic ocular fundus photography in the emergency department: Phase I of the FOTO-ED Study. Acad Emerg Med [internet]. 2011 [cited 10 September 2016]; 18(9): pp. 928-33. doi: 10.1111/j.1553-2712.2011.01147.x.

[19] Mottow-Lippa L, Boker JR and Stephens F. A prospective study of the longitudinal effects of an embedded speciality curriculum on physical examination skills using an ophthalmology model. Acad Med [internet]. 2009 [cited 28 September 2016]; 84(11): pp. 1622-30. doi: 10.1097/ACM.0b013e3181bb2d51.

Figure 3 – Hartley, M.J. – author creation

Total word count excluding references and title – 1,486