Dados do Trabalho

Título

Central Retinal Artery Occlusion: Point of Care Technology, Telestroke and Indirect Ophthalmoscopy Techniques

RESUMO

Apresentação do caso:
An 83-year-old man presented to the Emergency Department (ED) due to sudden non-painful left eye monocular vision loss 15h after he was last known well.
His neurological examination was notable for a left eye relative afferent pupillary defect and a left eye visual acuity of light perception at 30 cm with no other focal neurological deficits.
He was immediately taken to Radiology on stroke code and, during transport, mydriatic drops were instilled on his eyes. Approximately 20 mintues after first contact with Neurology, an indirect ophtalmoscopy done after neuroimaging with a 20 diopter lens and a smartphone camera confirmed a left eye central retinal artery occlusion (CRAO).

Discussão:
Most hospitals do not have an ophtalmologist on call 24h a day and formal specialized consultations can result in treatment delays in time sensitive situations such as stroke. It is essential neurologists in EDs are capable of perfoming good quality fundoscopies.
Although extensively advocated by the neurology education community as mandatory part of training, many neurologists are uncomfortable with the use of direct ophtalmoscopes. In addition, the 15° fundus view amplitude of direct ophtalmoscopy is very useful for optic disc pathology detection, but could potentially miss CRAO, in which optic discs are spared. Our proposed technique circumvents these drawbacks with a much wider, 360° view of the eye fundus, without adding a significant amount of time to the care of patients on acute stroke codes, since mydriatic drops can be used during the neurological exam or while transporting patients to imaging.
Furthermore, when the on call neurologist is not sure of the correct interpretation of the eye fundus, images can be sent via secure instataneous communicantion channels, such as mobile phone applications, for discussion with fellow and more experienced colleagues, ensuring tailored care delivery as in telestroke.
As limitations of our work, we emphasize some patients have absolute contra-indications to the use of mydriatic drops, the 15 minute delay it takes for pupillary dilation, the price of indirect ophtalmoscopy lens and the need for staff training.

Comentários finais:
CRAO diagnosis can only be established by good eye fundus exam. Indirect ophtalmoscopy with smarthphone camera is a powerful mean of rapidly making this diagnosis in the ED and broadening access to emergency stroke reperfusion therapy in select eligible patients.

Palavras Chave

Stroke, telemedicine, telestroke, neurology, ophthalmology, central retinal artery occlusion, ophthalmoscopy