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The ocular fundus examination is infrequently and poorly performed in the emergency department (ED) clinical settings, placing patients at risk for missed diagnosis of hypertensive emergencies. The aim of this study was to investigate the feasibility of the ocular fundus photography with a smartphone small optical device in an ED setting and to compare it with a traditional ocular fundus examination.The study included 52 consecutive patients (mean age 69 ± 16 years, 50% women) presenting to a hospital ED with an acute increase in blood pressure (SBP > 180 and/or DBP > 100 mmHg). When admitted to the ED all patients had mydriatic ocular fundus examination obtained by a medical student (observer 1) using both a traditional ophthalmoscope and a commercially available ocular fundus smartphone device (D-Eye, Si14 S.p.A., Padova, Italy), to assess the presence of grade III and IV Keith Wegener retinopathy. All ocular fundus images and videos recorded with the D-Eye system were analyzed by two independent expert (ophthalmologist – observer 2) and inexpert (medical student – observer 1) observers. A quantitative score of hemorrages, exudates and/or papillary edema was used (0 absent, 1 early, 2 moderate, 3 severe and 4 very severe). The Cohen K coefficient was used to assess the interobserver concordance index.The mean duration of ocular fundus examination was 130 ± 39 and 74 ± 31 s for traditional ophthalmoscopy and for smartphone D-Eye, respectively. No relevant abnormalities of the ocular fundus were detected by traditional ophthalmoscopy, performed by observer 1, whereas a significant number of abnormal ocular fundus findings were detected by the use of the D-Eye device in 17 and 19 patients by observer 1 and observer 2, respectively. The K coefficient value ranged from 0.66 to 0.77 (good concordance) for the assessment of hemorrhages and exudates, and from 0.89 to 0.90 (optimal concordance) for the evaluation of presence and severity of papilledema.Our results show that a new small smartphone device (D-Eye) may be feasible in an ED setting for the fundoscopic examination, detecting a significant number of abnormal ocular fundus. The reliability of relevant ocular fundus abnormalities seems to be superior in respect to traditional retinal fundoscopy.