Neuroimaging in patients referred to a neuro-ophthalmology service: the rates of appropriateness and concordance in interpretation

Maculopathies Referred to Neuro-Ophthalmology Clinic as Optic Neuropathies: A Case Series

BACKGROUND

The clinical features of maculopathies and optic neuropathies often overlap: Both present with decreased visual acuity and variable loss of color vision; thus, maculopathy can be misdiagnosed as optic neuropathy, leading to patient harm. We aimed to determine what findings and/or tests were most helpful in differentiating between optic neuropathy and maculopathy.

METHODS

A retrospective chart review of consecutive patients over 4.5 years who were referred to neuro-ophthalmology clinics with the diagnosis of optic neuropathy but whose final diagnosis was maculopathy. Patient demographics, mode of presentation, clinical profile, complete ophthalmological examination, results of all ancillary testing, and final diagnosis were recorded.

RESULTS

A total of 47 patients (27 women) were included. The median age was 55 years (range, 18-85). Most referrals were by ophthalmologists (72.3%) and optometrists (12.8%). The diagnosis of maculopathy was made in 51.1% of patients at the time of first neuro-ophthalmic consultation. Only 6.4% patients (3) had relative afferent pupillary defect. Benign disc anomalies (tilted, myopic, small, or anomalous discs) were present in 34.0%, and 21.3% had pathologic disc changes unrelated or secondary to maculopathy. Macular ocular coherence tomography (OCT) was abnormal in 84.4% (with outer retinal pathology in 42.2% and inner retina pathology in 17.8%). Retinal nerve fiber layer (RNFL) thickness was normal in 82.6% of patients.

CONCLUSIONS

Macular OCT is a high-yield test in differentiating between optic neuropathy and maculopathy and should be obtained in patients with suspected optic neuropathies who have normal RNFL thickness. Macular dystrophies, particularly cone dystrophies, unspecified retinal disorders, and macular degeneration were the most common mimics of optic neuropathy. The diagnosis was often present on OCT of the macula. The presence of coexistent benign and pathological disc anomalies may lead to maculopathy being misdiagnosed as optic neuropathy.

A Deep Learning System for Automated Quality Evaluation of Optic Disc Photographs in Neuro-Ophthalmic Disorders

The quality of ocular fundus photographs can affect the accuracy of the morphologic assessment of the optic nerve head (ONH), either by humans or by deep learning systems (DLS). In order to automatically identify ONH photographs of optimal quality, we have developed, trained, and tested a DLS, using an international, multicentre, multi-ethnic dataset of 5015 ocular fundus photographs from 31 centres in 20 countries participating to the Brain and Optic Nerve Study with Artificial Intelligence (BONSAI). The reference standard in image quality was established by three experts who independently classified photographs as of "good", "borderline", or "poor" quality. The DLS was trained on 4208 fundus photographs and tested on an independent external dataset of 807 photographs, using a multi-class model, evaluated with a one-vs-rest classification strategy. In the external-testing dataset, the DLS could identify with excellent performance "good" quality photographs (AUC = 0.93 (95% CI, 0.91-0.95), accuracy = 91.4% (95% CI, 90.0-92.9%), sensitivity = 93.8% (95% CI, 92.5-95.2%), specificity = 75.9% (95% CI, 69.7-82.1%) and "poor" quality photographs (AUC = 1.00 (95% CI, 0.99-1.00), accuracy = 99.1% (95% CI, 98.6-99.6%), sensitivity = 81.5% (95% CI, 70.6-93.8%), specificity = 99.7% (95% CI, 99.6-100.0%). "Borderline" quality images were also accurately classified (AUC = 0.90 (95% CI, 0.88-0.93), accuracy = 90.6% (95% CI, 89.1-92.2%), sensitivity = 65.4% (95% CI, 56.6-72.9%), specificity = 93.4% (95% CI, 92.1-94.8%). The overall accuracy to distinguish among the three classes was 90.6% (95% CI, 89.1-92.1%), suggesting that this DLS could select optimal quality fundus photographs in patients with neuro-ophthalmic and neurological disorders affecting the ONH.

Diagnostic Error in Neuro-ophthalmology: Avenues to Improve

Purpose of Review

To highlight potential avenues to reduce preventable diagnostic error of neuro-ophthalmic conditions and avoid patient harm.

Recent Findings

Recent prospective studies and studies of patient harm have advanced our understanding. Additionally, recent studies of fundus photography, telemedicine, and artificial intelligence highlight potential avenues for diagnostic improvement.

Summary

Diagnostic error of neuro-ophthalmic conditions can often be traced to failure to gather an adequate history, perform a complete physical exam, obtain adequate/appropriate neuroimaging, and generate a complete, appropriate differential diagnosis. Improving triage and identification of neuro-ophthalmic conditions by other providers and increasing access to subspecialty neuro-ophthalmology evaluation are essential avenues to reduce diagnostic error. Further research should evaluate the relationship between misdiagnosis and patient harm, and help identify the most impactful potential targets for improvement.

Evaluation of Diplopia by Emergency Medicine Physicians and Consulting Neurologists

BACKGROUND

Appropriate evaluation of diplopia requires separating serious from benign causes. If providers are not adept in this task, diagnosis of critical conditions may be delayed and unnecessary testing may result.

METHODS

We studied the records of 100 consecutive patients who presented to an emergency department between 2010 and 2020 with diplopia as a prominent symptom. We rated the performance of emergency medicine physicians (EMPs) and consulting neurologists (CNs) in the examination, diagnosis, and ordering of diagnostic tests according to standards based on neuro-ophthalmologic consultation and the neuro-ophthalmologic literature.

RESULTS

EMPs made no diagnosis or an incorrect diagnosis in 88 (88%) of 100 encounters. They ordered 14 unindicated and 12 incorrect studies, mostly noncontrast computed tomography scans. CNs made an incorrect diagnosis in 13 (31%) encounters. They ordered 6 unindicated and 2 incorrect studies. The total charge for unindicated and incorrect studies ordered by EMPs and CNs was $119,950.

CONCLUSIONS

EMPs and CNs made frequent errors in the examination, diagnosis, and ordering of diagnostic studies, leading to inefficient care and unnecessary testing. EMPs largely delegated the evaluation of diplopia to their consultants. If such consultative support were not available, the care of diplopic patients would be delayed. CNs performed more complete examinations, but rarely enough to allow appreciation of the pattern of ocular misalignment, contributing to misdiagnoses and ordering errors. The identification of these provider errors allows for more targeted teaching in the evaluation of diplopia.

Patient Harm Due to Diagnostic Error of Neuro-Ophthalmologic Conditions

PURPOSE

To prospectively examine diagnostic error of neuro-ophthalmic conditions and resultant harm at multiple sites.

DESIGN

Prospective, cross-sectional study.

PARTICIPANTS

A total of 496 consecutive adult new patients seen at 3 university-based neuro-ophthalmology clinics in the United States in 2019 to 2020.

METHODS

Collected data regarding demographics, prior care, referral diagnosis, final diagnosis, diagnostic testing, treatment, patient disposition, and impact of the neuro-ophthalmologic encounter. For misdiagnosed patients, we identified the cause of error using the Diagnosis Error Evaluation and Research (DEER) taxonomy tool and whether the patient experienced harm due to the misdiagnosis.

MAIN OUTCOME MEASURES

The primary outcome was whether patients who were misdiagnosed before neuro-ophthalmology referral experienced harm as a result of the misdiagnosis. Secondary outcomes included appropriateness of referrals, misdiagnosis rate, interventions undergone before referral, and the primary type of diagnostic error.

RESULTS

Referral diagnosis was incorrect in 49% of cases. A total of 26% of misdiagnosed patients experienced harm, which could have been prevented by earlier referral to neuro-ophthalmology in 97%. Patients experienced inappropriate laboratory testing, diagnostic imaging, or treatment before referral in 23%, with higher rates for patients misdiagnosed before referral (34% of patients vs. 13% with a correct referral diagnosis, P < 0.0001). Seventy-six percent of inappropriate referrals were misdiagnosed, compared with 45% of appropriate referrals (P < 0.0001). The most common reasons for referral were optic neuritis or optic neuropathy (21%), papilledema (18%), diplopia or cranial nerve palsies (16%), and unspecified vision loss (11%). The most common sources of diagnostic error were the physical examination (36%), generation of a complete differential diagnosis (24%), history taking (24%), and use or interpretation of diagnostic testing (13%). In 489 of 496 patients (99%), neuro-ophthalmology consultation (NOC) affected patient care. In 2% of cases, neuro-ophthalmology directly saved the patient's life or vision; in an additional 10%, harmful treatment was avoided or appropriate urgent referral was provided; and in an additional 48%, neuro-ophthalmology provided a diagnosis and direction to the patient's care.

CONCLUSIONS

Misdiagnosis of neuro-ophthalmic conditions, mismanagement before referral, and preventable harm are common. Early appropriate referral to neuro-ophthalmology may prevent patient harm.

Diagnostic Error of Neuro-ophthalmologic Conditions: State of the Science

BACKGROUND

Diagnostic error is prevalent and costly, occurring in up to 15% of US medical encounters and affecting up to 5% of the US population. One-third of malpractice payments are related to diagnostic error. A complex and specialized diagnostic process makes neuro-ophthalmologic conditions particularly vulnerable to diagnostic error.

EVIDENCE ACQUISITION

English-language literature on diagnostic errors in neuro-ophthalmology and neurology was identified through electronic search of PubMed and Google Scholar and hand search.

RESULTS

Studies investigating diagnostic error of neuro-ophthalmologic conditions have revealed misdiagnosis rates as high as 60%-70% before evaluation by a neuro-ophthalmology specialist, resulting in unnecessary tests and treatments. Correct performance and interpretation of the physical examination, appropriate ordering and interpretation of neuroimaging tests, and generation of a differential diagnosis were identified as pitfalls in the diagnostic process. Most studies did not directly assess patient harms or financial costs of diagnostic error.

CONCLUSIONS

As an emerging field, diagnostic error in neuro-ophthalmology offers rich opportunities for further research and improvement of quality of care.

National Trends in Imaging Rates for Eye-Related Emergency Department Visits in the United States

PURPOSE

To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits.

DESIGN

Retrospective, trend study.

METHODS

Setting: National Hospital Ambulatory Medical Care Survey 2007-2015.

PATIENT POPULATION

Eye-related ED patients who underwent CT or MRI.

MAIN OUTCOME MEASURE(S)

Population-based CT/MR imaging rates and independent factors associated with imaging.

RESULTS

An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR] = 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted.

CONCLUSIONS

Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted.

Referral Patterns in Neuro-Ophthalmology

BACKGROUND

Neuro-ophthalmologists specialize in complex, urgent, vision- and life-threatening problems, diagnostic dilemmas, and management of complex work-ups. Access is currently limited by the relatively small number of neuro-ophthalmologists, and consequently, patients may be affected by incorrect or delayed diagnosis. The objective of this study is to analyze referral patterns to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed diagnoses in patients ultimately referred, and delineate outcomes after neuro-ophthalmologic evaluation.

METHODS

Retrospective chart review of 300 new patients seen over 45 randomly chosen days between June 2011 and June 2015 in one tertiary care neuro-ophthalmology clinic. Demographics, distance traveled, time between onset and neuro-ophthalmology consultation (NOC), time between appointment request and NOC, number and types of providers seen before referral, unnecessary tests before referral, referral diagnoses, final diagnoses, and impact of the NOC on outcome were collected.

RESULTS

Patients traveled a median of 36.5 miles (interquartile range [IQR]: 20-85). Median time from symptom onset was 210 days (IQR: 70-1,100). Median time from referral to NOC was 34 days (IQR: 7-86), with peaks at one week (urgent requests) and 13 weeks (routine requests). Median number of previous providers seen was 2 (IQR: 2-4; range:0-10), and 102 patients (34%) had seen multiple providers within the same specialty before referral. Patients were most commonly referred for NOC by ophthalmologists (41% of referrals). Eighty-one percent (242/300) of referrals to neuro-ophthalmology were appropriate referrals. Of the 300 patients referred, 247 (82%) were complex or very complex; 119 (40%) were misdiagnosed; 147 (49%) were at least partially misdiagnosed; and 22 (7%) had unknown diagnoses. Women were more likely to be at least partially misdiagnosed-108 of 188 (57%) vs 39 of 112 (35%) of men (P < 0.001). Mismanagement or delay in care occurred in 85 (28%), unnecessary tests in 56 (19%), unnecessary consultations in 64 (22%), and imaging misinterpretation in 16 (5%). Neuro-ophthalmologists played a major role in directing treatment, such as preserving vision, preventing life-threatening complications, or avoiding harmful treatment in 62 (21%) patients.

CONCLUSIONS

Most referrals to neuro-ophthalmologists are appropriate, but many are delayed. Misdiagnosis before referral is common. Neuro-ophthalmologists often prevent vision- and life-threatening complications.

Diagnostic error and neuro-ophthalmology

PURPOSE OF REVIEW

This review summarizes the recent literature on diagnostic error relevant to the practice of neuro-ophthalmology, and evaluates the potential for increased access to neuro-ophthalmology to decrease rates of diagnostic error, thereby reducing medical harm and spending on unnecessary tests and treatments.

RECENT FINDINGS

Despite medical advances, current research continues to show alarmingly high rates of diagnostic error. Research into diagnostic error shows that many of these errors can be traced to cognitive errors. Recent studies on diagnostic problems relevant to neuro-ophthalmology, including studies of misdiagnosis of posterior communicating artery aneurysms, idiopathic intracranial hypertension, optic neuritis, and optic nerve sheath meningiomas, have identified major causes of diagnostic error in these conditions.

SUMMARY

Studies on diagnostic error in neuro-ophthalmologic conditions show that prior to evaluation by a neuro-ophthalmologist, patients may undergo unnecessary tests and treatments that are costly and potentially harmful. Further research on diagnostic error will inform better utilization of neuro-ophthalmologists as a resource to decrease diagnostic error.

Imaging in neuro-ophthalmology in the context of value-based care

PURPOSE OF REVIEW

Neuro-ophthalmic imaging is an invaluable tool for clinical decision-making and has evolved rapidly. At the same time, both imaging utilization and healthcare costs have skyrocketed, and concern for imaging overuse has become a salient topic. This article gives an overview of the current state of neuro-ophthalmic imaging from a value-based medicine lens and discusses recent neuro-ophthalmic advancements in OCT with these considerations in mind.

RECENT FINDINGS

Neuro-ophthalmology is not immune to the waste prevalent in medical imaging. Recent guidelines recommend against routine imaging for ophthalmic conditions without the presence of symptoms. Although neuro-ophthalmic specialty consults and imaging compare favorably against other specialties, the diagnostic yield depending on imaging indication can vary dramatically. For newer developments such as in OCT, it is particularly difficult to assess cost-effectiveness despite the technology's exciting diagnostic potential.

SUMMARY

Familiarity with guidelines to counter misuse, the diagnostic yield of imaging in particular situations, and the limitations of new technology can all help neuro-ophthalmologists make educated tradeoffs and adapt to the new landscape of cost-effective medicine. By helping to decrease costs and efficiently utilize limited resources, the end benefactors will be the increased number of patients who have greater access to affordable care.

Added value of double reading in diagnostic radiology,a systematic review

Objectives

Double reading in diagnostic radiology can find discrepancies in the original report, but a systematic program of double reading is resource consuming. There are conflicting opinions on the value of double reading. The purpose of the current study was to perform a systematic review on the value of double reading.

Methods

A systematic review was performed to find studies calculating the rate of misses and overcalls with the aim of establishing the added value of double reading by human observers.

Results

The literature search resulted in 1610 hits. After abstract and full-text reading, 46 articles were selected for analysis. The rate of discrepancy varied from 0.4 to 22% depending on study setting. Double reading by a sub-specialist, in general, led to high rates of changed reports.

Conclusions

The systematic review found rather low discrepancy rates. The benefit of double reading must be balanced by the considerable number of working hours a systematic double-reading scheme requires. A more profitable scheme might be to use systematic double reading for selected, high-risk examination types. A second conclusion is that there seems to be a value of sub-specialisation for increased report quality. A consequent implementation of this would have far-reaching organisational effects.

Key Points

• In double reading, two or more radiologists read the same images.

• A systematic literature review was performed.

• The discrepancy rates varied from 0.4 to 22% in various studies.

• Double reading by sub-specialists found high discrepancy rates.

Electronic supplementary material

The online version of this article (10.1007/s13244-018-0599-0) contains supplementary material, which is available to authorised users.

Over-diagnosis and over-treatment in Ophthalmology: A review of the literature

OBJECTIVE

To determine if the pernicious effects of over-diagnosis and over-treatment have been studied in the most common ocular diseases.

MATERIAL AND METHODS

Bibliographic search conducted in PubMed.

RESULTS

The search algorithm used retrieved 29 articles related with the topic. Most of them address the issue tangentially. Only 4 of them address the problem directly. One of them focuses on the problem of over-diagnosis and over-treatment in idiopathic intracranial hypertension. The remaining 3 focus on the problem of over-diagnosis and over-treatment in glaucoma.

CONCLUSION

The ophthalmology community has thought very little about the detrimental effects of over-diagnosis and over-treatment.

Imaging of the Postoperative Orbit

Imaging evaluation of the postoperative orbit remains challenging even for the expert neuroradiologist. This article provides a simplified framework for understanding the complex postoperative appearances of the orbit, in an attempt to enhance the diagnostic accuracy of postoperative computed tomography and MR imaging of the orbit. Readers are familiarized with the normal appearances of common eye procedures and orbit reconstructions to help avoid interpretative pitfalls. Also reviewed are imaging features of common surgical complications, and evaluation of residual/recurrent neoplasm in the setting of oncologic imaging surveillance.

Neuro-Ophthalmology Annual Review

The aim of this study was to update the practicing ophthalmologist on the English-language neuro-ophthalmology literature from the prior year. This study is a review of English-language literature from August 1, 2012, to August 1, 2013. The authors searched PubMed articles published from August 1, 2012, to August 1, 2013, limited to English-language publications including original articles, review articles, and case reports and excluding letters to the editor, unpublished work, and abstracts. We researched the following topics: pupillary abnormalities, eye movement dysfunction, neuromuscular diseases, optic neuropathies, optic neuritis and demyelinating disease including multiple sclerosis, lesions of the chiasm and posterior primary visual pathways, elevated intracranial pressure, tumors and aneurysms affecting the visual pathways, vascular diseases, higher visual functions, and neuroimaging advances. We intend to share clinically relevant literature of the past year with the practicing ophthalmologist. We aimed to highlight remarkable and interesting literature rather than exhaustively including all new neuro-ophthalmological publications of the year. We reviewed literature in the past year with a focus on relevance and novelty. This review updates the comprehensive ophthalmologist on neuro-ophthalmic topics.