Fundus Photography


Fundus Photography

Synonym/acronym: N/A.

Common use

To evaluate vascular and structural changes in the eye in assessing the progression of diseases such as glaucoma, diabetic retinopathy, and macular degeneration.

Area of application

Eyes.

Contrast

N/A.

Description

This test involves the photographic examination of the structures of the eye to document the condition of the eye, detect abnormalities, and assist in following the progress of treatment.

This procedure is contraindicated for

  • high alert Patients with narrow-angle glaucoma if pupil dilation is performed; dilation can initiate a severe and sight-threatening open-angle attack.
  • high alert Patients with allergies to mydriatics if pupil dilation using mydriatics is performed.

Indications

  • Detect the presence of choroidal nevus
  • Detect various types and stages of glaucoma
  • Document the presence of diabetic retinopathy
  • Document the presence of macular degeneration and any other degeneration and any associated hemorrhaging
  • Observe ocular effects resulting from the long-term use of high-risk medications

Potential diagnosis

Normal findings

  • Normal optic nerve and vessels
  • No evidence of other ocular abnormalities

Abnormal findings related to

  • Aneurysm
  • Atrial hypertension
  • Benign intracranial hypertension from brain tumor
  • Choroidal nevus
  • Color vision deficiencies
  • Diabetic retinopathy
  • Disorders of the optic nerve
  • Glaucoma
  • Histoplasmosis
  • Macular degeneration
  • Obstructive disorders of the arteries or veins that lead to collateral circulation
  • Papilledema
  • Raised intracranial pressure associated with hydrocephalus
  • Retinal detachment or tear
  • Sickle cell anemia
  • Stroke

Critical findings

  • Detached retina

  • Flashers, floaters, or a veil that moves across the field of vision may indicate detached retina or retinal tear. This condition requires immediate examination by an ophthalmologist. Untreated, full retinal detachment can result in irreversible and complete loss of vision in the affected eye.

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Factors that may impair the results of the examination

    • Inability of the patient to cooperate or remain still during the test because of age, significant pain, or mental status may interfere with the test results.
    • Presence of cataracts may interfere with fundal view.
    • Ineffective dilation of the pupils may impair clear imaging.
    • Rubbing or squeezing the eyes may affect results.
    • Failure to follow medication restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure assists in detecting changes in the eye that effect vision.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially mydriatics if dilation is to be performed.
  • Obtain a history of the patient’s known or suspected vision loss; changes in visual acuity, including type and cause; use of glasses or contact lenses; and eye conditions with treatment regimens.
  • Obtain results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Instruct the patient to remove contact lenses or glasses, as appropriate. Instruct the patient regarding the importance of keeping the eyes open for the test.
  • Review the procedure with the patient. Explain that the patient will be requested to fixate the eyes during the procedure. Address concerns about pain and explain that mydriatics, if used, may cause blurred vision and sensitivity to light. There may also be a brief stinging sensation when the drop is put in the eye, but no discomfort will be experienced during the examination. Inform the patient that an HCP performs the test, in a quiet, darkened room, and that to dilate and evaluate both eyes, the test can take up to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Note that there are no food or fluid restrictions, unless by medical direction.
  • Instruct the patient to avoid eye medications (particularly miotic eye drops which may constrict the pupil preventing a clear view of the fundus and mydriatic eyedrops in order to avoid instigation of an acute open angle attack in patients with narrow angle glaucoma) for at least 1 day prior to the test.
  • Ensure that the patient understands that he or she must refrain from driving until the pupils return to normal (about 4 hr) after the test and has made arrangements to have someone else be responsible for transportation after the test.

Intratest

  • Potential complications:

  • Dilation can initiate a severe and sight-threatening open-angle attack in patients with narrow-angle glaucoma.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has complied with medication restrictions; ensure that eye medications, especially miotics and mydriatics, have been restricted for at least 1 day prior to the test.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still during the procedure because movement produces unreliable results.
  • Seat the patient in a chair that faces the camera. Instruct the patient to look at a directed target while the eyes are examined.
  • Administer the ordered mydriatic to each eye and repeat in 5 to 15 min if dilation is to be performed. Drops are placed in the eye with the patient looking up and the solution directed at the six o’clock position of the sclera (white of the eye) near the limbus (gray, semitransparent area of the eyeball where the cornea and sclera meet). Neither dropper nor bottle should touch the eyelashes.
  • Instruct the patient to place the chin in the chin rest and gently press the forehead against the support bar. Instruct the patient to open his or her eyes wide and look at desired target while a sequence of photographs are taken.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual medications, as directed by the HCP.
  • Nutritional Considerations: Increased glucose levels may be associated with diabetes. There is no “diabetic diet”; however, many meal-planning approaches with nutritional goals are endorsed by the American Dietetic Association. Patients who adhere to dietary recommendations report a better general feeling of health, better weight management, greater control of glucose and lipid values, and improved use of insulin. Instruct the patient, as appropriate, in nutritional management of diabetes. The 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Risk published by the American College of Cardiology (ACC) and the American Heart Association (AHA) in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) recommends a “Mediterranean”-style diet rather than a low-fat diet. The new guideline emphasizes inclusion of vegetables, whole grains, fruits, low-fat dairy, nuts, legumes, and nontropical vegetable oils (e.g., olive, canola, peanut, sunflower, flaxseed) along with fish and lean poultry. A similar dietary pattern known as the Dietary Approaches to Stop Hypertension (DASH) diet makes additional recommendations for the reduction of dietary sodium. Both dietary styles emphasize a reduction in consumption of red meats, which are high in saturated fats and cholesterol, and other foods containing sugar, saturated fats, trans fats, and sodium. If triglycerides also are elevated, the patient should be advised to eliminate or reduce alcohol. The nutritional needs of each diabetic patient need to be determined individually (especially during pregnancy) with the appropriate HCPs, particularly professionals trained in nutrition.
  • Recognize anxiety related to test results, and be supportive of impaired activity related to vision loss or anticipated loss of driving privileges. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Emphasize, as appropriate, that good glycemic control delays the onset of and slows the progression of diabetic retinopathy, nephropathy, and neuropathy. Provide education regarding smoking cessation, as appropriate. Provide contact information regarding vision aids, if desired, for ABLEDATA (sponsored by the National Institute on Disability and Rehabilitation Research [NIDRR], available at www.abledata.com). Information can also be obtained from the American Macular Degeneration Foundation (www.macular.org), the American Diabetes Association (www.diabetes.org), or the American Heart Association (www.americanheart.org).
  • Instruct the patient to avoid strenuous physical activities, like lifting heavy objects, that may increase pressure in the eye, as ordered.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient that visual acuity and responses to light may change. Suggest that the patient wear dark glasses after the test until the pupils return to normal size. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include fluorescein angiography, fructosamine, glucagon, glucose, glycated hemoglobin, gonioscopy, insulin, intraocular pressure, microalbumin, plethysmography, refraction, slit-lamp biomicroscopy, and visual field testing.
  • Refer to the Ocular System table at the end of the book for related tests by body system.