Results

All doctors surveyed felt funduscopy was important but only eight felt it should be performed on all patients and only three doctors routinely perform funduscopy. Half (49%) would perform funduscopy for patients with diabetes mellitus, hypertension, visual impairment, and neurological symptoms. The more senior doctors were more likely to have performed more funduscopies in the preceding 3 months than junior doctors (Cuzick's test for trend 2-tail p = 0.0005). Only 18 (44%) doctors were confident in performing funduscopy, 34 (83%) felt they would benefit from more training, 30 (73%) had had insufficient training in funduscopy and most (97%) believed their funduscopy skills could be improved. All 41 do not routinely dilate the pupil before funduscopy for a number of reasons: insufficient time (19), concern at inducing glaucoma (10), don't know how to dilate (nine), and don't think it's necessary (three). Reasons given for not performing funduscopy included: insufficient time (12), not skilled enough (nine), lack of available equipment (four), and not useful (one).

A correct diagnosis was more likely to be made from looking at a slide than from funduscopy, suggesting a lack of skill in funduscopy technique (table).

Review of 100 case notes showed that only three patients had had funduscopy documented. All these patients had diabetes mellitus. Nine patients with diabetes and 35 with hypertension had no funduscopy recorded. The majority of patients (97) reported a visual defect ranging from glasses for reading (28), cataracts (22), blurred vision (18), myopia (15), hyperopia (six), wavy lines (three), and visual problem of uncertain nature (five).

Half (49%) were concerned about their eyesight, but only 13 patients had been asked about visual problems by their hospital doctor; three of these patients recalled the doctor examining their eyes. The mean time since review by an optician was 3.5 years. Only nine patients were deterred from going to the optician by having to pay.

Discussion

Visual problems are common in older people. In this study the majority of patients had some type of visual impairment. On enquiry, some patients were experiencing specific problems but few had mentioned this to their doctor. There may be several reasons for this under-reporting, including decreased expectations in old age and a belief that nothing can be done,4 as well as lack of enquiry by medical staff. Of concern is that only 23% of patients who specifically reported a visual problem could recall having their eyes examined (confirmed by case note review). Many patients (49%) were concerned about their eyesight. Since most are not deterred from going to the optician by having to pay and there is some concern about screening in the community by general practitioners (of patients over 75 years),5 one possible solution is to encourage older people to go to the optician on a regular basis (say, once every 2 years). There was a wide variation in this study in the frequency of going to the optician (some patients going on a regular basis whilst some had never been). Since some of the patients who had never seen an optician were not deterred by the prospect of having to pay, there may be a role for health education, although there may be other explanations for not going to the optician (eg, poor mobility). Doctors should be aware that not all older patients complain of visual problems and specific enquiry should be made.

Although only half of the doctors said they would perform funduscopy for patients with diabetes mellitus, hypertension, visual impairment, and neurological symptoms, most elderly patients with these conditions had not had funduscopy performed.

Participation in looking at the slides and fundi was poor, even though doctors were reassured that the results would be anonymous. There are probably several reasons for this but it may reflect apprehension by some doctors regarding their skill in funduscopy. It is unlikely that those who did not participate are any better at interpretation than those who did. Doctors were more likely to diagnose a fundal abnormality correctly from a slide than from actual funduscopy, which suggests that it is a problem with technique rather than lack of knowledge. Unfortunately, the numbers participating were too small to draw any significant conclusion.

There are multiple reasons why funduscopy is not done; in this study the main reason given was insufficient time. Increasing acute admissions to hospital with increasing demands on hospital doctor time may lead to omission of funduscopy, once an integral part of the physical examination. This may, in turn, have an impact on training, not to mention patient care, ultimately resulting in a generation of doctors unskilled in this procedure and funduscopy becoming a forgotten art known only to the ophthalmologists.

We believe that funduscopy should remain an integral part of the physical examination. It is a skill acquired through training and practise. Training in this technique should be considered part of general professional training in medicine and should be encouraged by physicians. With increasing cross-cover, one option would be to involve senior house officers on a medical rotation with those in ophthalmology. An alternative option would be to provide protected teaching for junior medical staff from an ophthalmologist or senior physician skilled in funduscopy. Senior physicians should not be complacent that their junior staff are learning funduscopy the same way that they did, ie, by performing it. Clinical medicine is changing with ever-increasing pressure on time to see more and more acute patients. Junior doctors may well feel that they do not have time to perform funduscopy and if senior doctors fail to comment, this maybe interpreted as tacit agreement that funduscopy is irrelevant.

In conclusion, few older patients are having funduscopy performed as part of the routine physical examination and many doctors feel their training in funduscopy has been inadequate and their skill in this technique could be improved.