Ophthalmoscopy in the 21st century: The 2017 H. Houston Merritt Lecture.

Although the usefulness of viewing the ocular fundus is well-recognized, ophthalmoscopy is infrequently and poorly performed by most nonophthalmologist physicians, including neurologists. Barriers to the practice of ophthalmoscopy by nonophthalmologists include not only the technical difficulty related to direct ophthalmoscopy, but also lack of adequate training and discouragement by preceptors. Recent studies have shown that digital retinal fundus photographs with electronic transmission and remote interpretation of images by an ophthalmologist are an efficient and reliable way to allow examination of the ocular fundus in patients with systemic disorders such as diabetes mellitus. Ocular fundus photographs obtained without pharmacologic dilation of the pupil using nonmydriatic fundus cameras could be of great value in emergency departments (EDs) and neurologic settings. The Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study showed that ED providers consistently failed to correctly identify relevant ocular funduscopic findings using the direct ophthalmoscope, and that nonmydriatic fundus photography was an effective alternate way of providing access to the ocular fundus in the ED. Extrapolating these results to headache clinics, outpatient neurology clinics, and adult and pediatric primary care settings seems self-evident. As technology advances, nonmydriatic ocular fundus imaging systems will be of higher quality and more portable and affordable, thereby circumventing the need to master the use of the ophthalmoscope. Visualizing the ocular fundus is more important than the method used. Ocular fundus photography facilitates nonophthalmologists' performance of this essential part of the physical examination, thus helping to reestablish the value of doing so.