• 
• 

Three Part Question

In [patients with suspected Retinal Detachment, Posterior Vitreous Detachment or Vitreous Haemorrhage presenting to the Emergency department] is [ocular ultrasound] along with standard ocular examination [highly sensitive and specific] for diagnosis?

Clinical Scenario

An adult male presents to the ED with flashes and floaters, and a curtain falling across the eye. Following standard ocular examination, there is a suspicion of RD, PVD or VH.
Could ocular ultrasound performed by an ED physician help in confirming the diagnosis and accelerate his further management?

Search Strategy

The following databases/ search engines were queried:
1. MEDLINE 1951 to date
2. COCHRANE Library
3. Google scholar

Terms used:
1. MEDLINE; exp *ULTRASONOGRAPHY/; 101402 results.
2. MEDLINE; exp *RETINAL DETACHMENT/di [di=Diagnosis]; 643 results.
3. MEDLINE; exp *VITREOUS DETACHMENT/di [di=Diagnosis]; 41 results.
4. MEDLINE; exp *VITREOUS HEMORRHAGE/di [di=Diagnosis]; 55 results.
5. MEDLINE; 2 OR 3 OR 4; 720 results.
6. MEDLINE; 1 AND 5; 44 results.
We used the same terminology for other search engines.

A total of 44 papers were retrieved, of which 7 were found relevant to all parts of question. Additionally 5 studies by the radiology and ophthalmology departments reporting on the sensitivity of US in diagnosing ocular pathologies have been included.

Search Outcome

There isn’t any level 1or 2 evidence available in the literature relevant to my three part question but the available evidence does show that ocular US is highly sensitive to diagnose RD, PVD and VH in the EDs.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Blaivas et al, 2002, USA	61 pts with ocular complaints ED	Single blinded, prospective, observational study	Sensitivity 100%	Specificity 97.2%	Non randomized Small sample Convenience sample Training issues No consent information
Shinar et al, 2009, USA	92 examinations, Adult ED	Prospective, observational study	Sensitivity 97%	Specificity 92%	Small sample Training issues No consent information Convenience sample
Rabinowitz et al, 2004, Israel	96 pts, 106 eyes, Adults, With dense Vitreous haemorrhage	Retrospective, Case series	100% sensitivity	100% specificity	Small number, Selection bias, No consent documentation, No Ethical approval and No operator training documentation
Lorenzo-Carrero et al, 2009 USA	239 pts, Adults, Mean age 65yrs	Prospective, cross sectional, Single blinded	96.4% sensitive	98% specific	Selection bias Small sample
Kim and Lee, 2005, Korea	81 pts with dense vitreous hemorhage	Retrospective study	89% sensitive	92% specific	Abstract, no statistical method, small number

Editor Comment

Author currently has 30 pts on a case series

Clinical Bottom Line

There isn’t any level 1or 2 evidence available in the literature relevant to my three part question but the available evidence does show that ocular US is highly sensitive to diagnose RD, PVD and VH in the EDs.

References

1. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the Emergency department. Acad Emerg Med 2002;9(8):791-9.
2. Shinar Z, Chan L, Orlinsky M. Use of Ocular Ultrasound for the Evaluation of Retinal Detachment. J Emerg Med 2011 ;40(1):53-7.
3. Kahn A; Khan AL; Corinaldi CA et al. Retinal Detachment Diagnosed by Bedside Ultrasound in the Emergency Department. The California Journal of Emergency Medicine 2005; 6(3): 47–51.
4. Elia J , Borger R. Diagnosis of Retinal Detachment in the ED with Ultrasonography Journal of Emergency Medicine 2009 Volume 37, Issue 4, Pages 415-416.
5. Buzzard AK, Linklater DR, Pediatric retinal detachment due to Coats' disease diagnosed with bedside emergency department ultrasound. The journal of emergency medicine 2009; 37(4):390-2.
6. Lewin MR, Williams SR, Ahuja Y. Ultrasonographic diagnosis of retinal detachment in the emergency department. Annals of Emergency Medicine 2005; Volume 45, Issue 1 , Pages 97-98.
7. R Rabinowitz, R Yagev, A Shoham et al. Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage. Eye 2004, 18, 253–256.
8. Cabric E, Salihefendic N, Zildzic M et al. Early Ultrasonographic diagnosis of retinal detachment: multidisciplinary approach and benefit. Med Arh. 2010;64(1):41-3.
9. Lorenzo-Carrero J, Perez-Flores I, Cid-Galano M, et al. B-scan ultrasonography to screen for retinal tears in acute asymptomatic Age related posterior vitreous detachment Opthalmology 2009; 116(1):94-9.
10. Innes J, McCreath G, Forrester JV. Ultrasonic patterns in Vitreo- Retinal disease Clin Radiol. 1982;33(5):585-91.
11. S. Kim and S. Lee. Comparison of Ultrasound and Intra-operative findings in patients with Vitreous haemorrhage. Invest Ophthalmol Vis Sc 2005 46: E-Abstract 5436.