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Patients presenting with neuro-ophthalmic disorders pose a diagnostic challenge when they present to community hospital emergency departments (ED) where expertise in neuro-ophthalmology is often limited. Many have no ophthalmology coverage or have a call group composed of general ophthalmologists who are not comfortable managing neuro-ophthalmic disorders. The limited familiarity with neuro-ophthalmology and the lack of essential equipment, such as a fundus camera or optical coherence tomography (OCT), contribute to a substantial gap in accurate and timely diagnosis and treatment. This deficiency results in patients making multiple visits to the emergency department, where they receive limited or no treatment, and this overall increases the risk of disease progression and potentially blindness.

Advocating for standardized protocols and integrating technological advancements will aid non-ophthalmologist physicians and mid-level physician extenders in the initial assessment and management of patients with acute visual issues. Additionally, improving the accessibility of neuro-ophthalmological services through telehealth, and diagnostic aids (such as smartphone-based fundus cameras) in emergency department settings is essential to avoid overlooked or misdiagnosed neuro-ophthalmological disorders.

We describe two common scenarios that illustrate the diagnostic journey of patients. One is a young patient presenting with headache and vague visual symptoms and the other is an elderly patient with unilateral visual loss and vague headaches. We will focus on the crucial role of the fundus camera/OCT in identifying disc edema but also discuss the key questions that help guide diagnosis.