Diagnostic yield of the routine dilated fundus examination

Objective: This study aimed to estimate the risk of errors of omission inherent in the elimination of the routine dilated fundus examination in asymptomatic patients presenting for routine eye checkups, or in patients with purely refractive complaints. Design: The study design was a retrospective chart review. Participants: The authors reviewed the records of initial visits of more than 3800 patients drawn from the practices of 3 board-certified ophthalmologists with substantial general ophthalmology components. Patients with best-corrected visual acuity in either eye of poorer than 20/25, myopia greater than -3.00 diopters, or other risk factors for disease of the fundus or optic nerve (such as ocular hypertension, glaucoma, previous ocular surgery, diabetes mellitus, and history of retinal detachment) were excluded. The authors identified 1094 such records that documented the findings of dilated fundus examination, including indirect ophthalmoscopy. Main Outcome Measures: The authors recorded the prevalence of all fundus abnormalities, of those deemed clinically significant, and those beyond the view of routine examination with the direct ophthalmoscope. Findings were stratified by patient age. Results: Of the 1094 eligible records, 53 (4.84%) had recorded fundus abnormalities. Of these, 23 were of no adverse ophthalmologic consequence and were considered clinically insignificant. Of the 30 (2.74%) potentially significant findings, only 3 were located beyond the view of routine examination with the direct ophthalmoscope (0.274%; 95% confidence limits: 0.56%-0.80%). The prevalence of fundus findings increased strongly with increasing patient age, from 2.4% younger than age 20 to 14.8% older than age 60. Clinically significant findings increased from 0.8% younger than age 20 to 8.9% older than age 60. Conclusions: The authors estimate the rate of detection through routine dilated fundus examination of clinically significant fundus lesions in asymptomatic patients at 2.73% (95% confidence limits, 1.86%-3.80%). One tenth of these are beyond the view of the direct ophthalmoscope. The prevalence of fundus abnormalities increases tenfold with increasing patient age.