Democratising fundoscopy: Using novel technology and education to make the ocular fundus accessible beyond ophthalmology

Abstract

Fundoscopy is an invaluable clinical examination, offering a direct view of the neurovascular system, yet it remains rarely and poorly performed by non-eye health practitioners. The technical challenges of viewing the fundus with the traditional ophthalmoscope mean that critical information is overlooked in current practice, to the detriment of patients. This thesis explores whether fundoscopy by non-eye health experts can be improved using novel technologies and optimised education.

Part 1 reviews the historical context and existing literature on fundoscopy. Part 2 describes three studies focussed on fundoscopy use and education across a spectrum of medical training. Smartphone fundoscopy was demonstrated to improve the ease of use, usability and diagnostic accuracy of fundoscopy for medical students. Additionally, e-learning modestly improved fundus interpretation. Part 3 describes four studies in which portable, digital fundoscopy tools and screening protocols were implemented in Emergency Departments in metropolitan and regional NSW, tertiary-hospital diabetic clinics, and amongst neurology inpatients. Clinically important prevalences of otherwise-missed, blinding and life-threatening pathology were detected in all settings. The detection of pathology and normalcy was enhanced, resulting in significant improvements in patient outcomes across a spectrum of medical contexts. Specialist telemedicine diagnostic support was required for optimal diagnostic accuracy.

In conclusion, the ocular fundus has always held a wealth of clinical findings with implications outside ophthalmology, and the proliferation of novel fundus-imaging technologies, alongside better-targeted education, promises to unlock the clinical riches of a non-invasive view of the neurovascular system. This thesis helps to quantify the current and potential future value of fundoscopy; direct efforts to democratise fundoscopy, and; better integrate it into clinical practice beyond the ophthalmic clinic.