The Role of Fundoscopy in the Emergency Department in Children with First Unprovoked Seizure. A retrospective Single Center Study

Introduction: Seizure is a common presentation in the pediatric emergency department (PED). Our institutional practice guidelines include routine fundoscopy by ophthalmologists in the PED to rule out papilledema to guide the urgency for further imaging in patients with normal neurological examination.

Our aim was to evaluate the clinical significance of fundoscopy in children with a first unprovoked seizure and a normal neurological examination.

Methods: In this retrospective study over a 5-years period (2015-2020) we included all children who presented with seizures to our PED who had normal neurological examination and underwent fundoscopy. Criteria for exclusion were children with fever, head injury, electrolyte disorders or previous abnormal fundoscopy. Primary outcome measure was the rate of brain imaging following an abnormal fundoscopy. Secondary outcome measure was the rate of repeat fundoscopy among admitted patients.

Results: The medical records of 1947 patients with seizures were reviewed. 649 patients underwent fundoscopy of whom 76 patients underwent neuroimaging, 36 patients were included, out of which 2 patients (0.3%) had an abnormal fundoscopic evaluation (CT scan and lumbar puncture were normal). 49 hospitalized patients underwent a second fundoscopic examination by an ophthalmology specialist. One patient had a suspected papilledema, after which he had a CT scan and an LP (which were normal).

Discussion: In our study, fundoscopic examination in the ED for children with first unprovoked seizure and normal neurological examination was not clinically significant.

In view of the limitations of the examination, which requires skill, time and cooperation, its role in the ED is questionable.