The Role of Fundoscopy Before Lumbar Puncture in Children with Suspected Meningitis

TL;DR

This study finds that routine eye exams before spinal taps in children with suspected meningitis rarely detect serious issues and may delay needed treatment.

Contribution

A large multicenter study shows fundoscopy detects papilledema in only 2.8% of cases and does not prevent LP contraindications.

Findings

Fundoscopy detected papilledema in 2.8% of 1,742 children with suspected meningitis.

Children who had fundoscopy received antibiotics less frequently before lumbar puncture.

No fundoscopy findings identified contraindications to lumbar puncture.

Abstract

To assess the diagnostic yield and clinical impact of fundoscopy before lumbar puncture (LP) in children with suspected meningitis.

A multicenter retrospective cohort study across 15 pediatric emergency departments, including children aged 18 months–18 years with suspected meningitis between July 2018 and June 2023. The primary outcome was papilledema prevalence; secondary outcomes were subsequent abnormal neuroimaging, LP deferral, and time to antibiotics.

Among 1,742 children (median age 4.6 years), bacterial meningitis was confirmed in 56 (3.2%). Fundoscopy was performed by ophthalmology residents in 959 (55.1%). Papilledema was identified in 27 (2.8%); all underwent CT, which revealed no contraindications to LP, and all proceeded to LP. Three children with normal fundoscopy who underwent LP were later found to have CT abnormalities (brain abscess and tumor); none of which led to adverse outcomes. Antibiotics were administered before LP less often when fundoscopy was performed (42.6% vs 58.8%, p < 0.001), although median time to antibiotics was similar (341 vs 269 min, p = 0.52). Children who had a head CT without fundoscopy received antibiotics earlier (239 vs 341 min; p = 0.039), and more frequently before LP (64.3% vs 42.6%, p < 0.001).

Conclusions: Routine fundoscopy before LP rarely detected papilledema, did not identify contraindications to LP, and was associated with lower rates of early antibiotic treatment. These findings suggest that fundoscopy adds little to safe LP decision-making and may inadvertently delay care in time-critical meningitis. A selective, clinically guided pre-LP approach, rather than routine fundoscopy, could streamline evaluation and improve practice.
What is known:• Fundoscopy is often performed before lumbar puncture (LP) in children with suspected meningitis to detect papilledema and guide decision about neuroimaging.• Evidence for its diagnostic yield and clinical impact in pediatric emergency settings is limited.What is new:• In a multicenter cohort of 1,742 children, fundoscopy (performed by ophthalmology residents) detected papilledema in only 2.8% of cases and revealed no contraindications to LP.• Fundoscopy was associated with lower rates of early antibiotic administration.

What is known:

• Fundoscopy is often performed before lumbar puncture (LP) in children with suspected meningitis to detect papilledema and guide decision about neuroimaging.

• Evidence for its diagnostic yield and clinical impact in pediatric emergency settings is limited.

What is new:

• In a multicenter cohort of 1,742 children, fundoscopy (performed by ophthalmology residents) detected papilledema in only 2.8% of cases and revealed no contraindications to LP.

• Fundoscopy was associated with lower rates of early antibiotic administration.