P2.161: Ocular Point-of-Care Ultrasound and Nonmydriatic Fundus Photography for Evaluation of Papilledema in the Pediatric Emergency Department

Background: Papilledema may result from life and/or vision threatening elevations in intracranial pressure (ICP). Emergent referrals for suspected elevated ICP require significant human and imaging resources. Indirect ophthalmoscopy by an ophthalmologist is currently the gold standard for evaluation of papilledema, however can result in prolonged emergency department (ED) stays or even require transfer to a tertiary care facility. Recently, ocular point-of-care ultrasound (POCUS) and nonmydriatric fundus photography (NFP) are two strategies that enable non-ophthalmologists to determine if papilledema is present or absent. Our study examined the feasibility and accuracy of ocular POCUS and NFP by non-ophthalmologists to evaluate for papilledema.

Methods: We prospectively recruited children age 3-17 years presenting to a large tertiary care pediatric ED for whom ophthalmology was consulted to evaluate for papilledema. We excluded those with ocular trauma or infection or whose eyes had been dilated in the last 24 hours. Participants underwent ocular POCUS and NFP by trained pediatric emergency medicine (PEM) clinicians prior to dilated ophthalmologic exam. Following study procedures, we administered surveys assessing feasibility to participants and clinicians performing study procedures. Ultrasound images were reviewed retrospectively by a masked PEM physician with subspecialty training in pediatric ultrasound, and fundoscopic photos were reviewed retrospectively by a masked pediatric neuro-ophthalmologist, to determine both interpretability as well as clinical findings. Our primary outcome was percent of participants for whom ocular POCUS and NFP was interpretable. We used standard descriptive statistics to describe survey results (each survey question was answered using a 10-point Likert scale, 0 = strong disagreement, 10 = strong agreement). We calculated kappa to determine correlation between POCUS and NFP as well as sensitivity and specificity for POCUS and NFP using the dilated exam as the gold standard.

Results: We enrolled 18 participants between August 2024-March 2025; participant demographics are summarized in Table 1. In total, 17/18 (94%) had interpretable ocular POCUS and 17/18 (94%) had interpretable NFP. Patients found both POCUS and NFP to be very comfortable, and clinicians found both POCUS and NFP very easy to use (Table 2). Kappa between POCUS and NFP was 0.51. Sensitivity and specificity were 0.75 and 0.88 for POCUS, and 0.88 and 0.75 for NFP.

Conclusion: Our preliminary results suggest that ocular POCUS and NFP are tolerable for pediatric patients and easy to use for providers in the ED, representing feasible alternative evaluation techniques for papilledema in the pediatric ED setting. Our analysis exhibited moderate agreement between POCUS and NFP, and reasonable Se and Sp compared to a dilated ophthalmology fundoscopic exam. Our current results are limited by small sample size, but additional enrollment of study participants is ongoing.