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Three Part Question

In [patients with suspected retinal detachment] can [bedside ultrasound] [confirm the diagnosis]?

Clinical Scenario

A 60-year-old female attends the emergency department complaining of floaters and visual loss affecting her right eye. You are concerned that she may have suffered a retinal detachment but are unable clinically to gain a clear view of the fundus. You wonder if ocular ultrasound would be helpful in diagnosing retinal detachment.

Search Strategy

((ultrasonography OR sonography OR ultrasound OR ultrasonics OR ultrasonography) AND (retina OR retinal OR detachment) AND (casualty OR emergency)).ti,ab
Medline 1950 - 23rd September 2013 using the OVID interface.
Embase - 1980 to 23rd September 2013
British Nursing Index – 1985 to 23rd September 2013
CINAHL – 1981 to 23rd September 2013

I also searched the Cochrane database, Google scholar and the reference lists of the relevant papers I had found were hand searched for any other relevant articles

Search Outcome

In total 58 papers were identified using this search strategy, of which 8 were relevant to my clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Yoonessi R et al 2010 USA	48 patients presenting to the ED with acute (less than 48 h in duration) visual change who required an ophthalmology review within 12 h of presentation. The criterion standard for retinal detachment was the final diagnosis given by the ophthalmologist who was blinded to the results of the ED ocular ultrasound. All participating emergency practitioners completed an introductory course on emergency ultrasound in the first week of their PGY­2 year, received a 20-min lecture with examples of normal and abnormal ocular pathology and completed one emergency ocular ultrasound scan on a normal volunteer	Prospective, observational study	Detection of retinal detachment	RD present in 18 patients. Sensitivity 100% (95% CI 78% to 100), Specificity 83% (95% CI 65% to 94%)	Small numbers 75% of eligible patients had to be excluded due to unavailability of an emergency physician sonographer
Khan et al 2005 USA	1 patient who presented to the ED with decreased visual acuity	Case report		Retinal detachment was found using ocular ultrasound	This is a case report which therefore has a low level of evidence
Blaivas et al 2002 USA	61 patients presenting with ocular trauma or visual change. Ophthalmic evaluation and CT were used as the gold standard. US were performed by attending physicians who had attended a 1 h lecture and 1 h hands-on instruction on ocular sonography	Prospective observational study	Diagnosis of ocular pathology including RD	8 patients with RD. 100% sensitivity and specificity	Small numbers No sample size or power calculation performed Convenience sample
Shinar et al 2011 USA	90 ED patients with suspected RD. Gold standard was ophthalmologist opinion. Practitioners received a 30-min lecture on ocular ultrasound	Prospective observational study	Detection of retinal detachment	29 patients out of 92 assessed had a final diagnosis of RD. US was performed with a sensitivity of 96.5% (95% CI 82% to 100%) and a specificity of 92.0% (95% CI 68% to 95%)	Convenience sample Wide confidence intervals Ophthalmologists were not blinded to the diagnosis made by the emergency department practitioners.
Palma J, Schott E 2013 USA	A patient presenting to the Emergency department with blurred vision and visaul loss.	Case report		Bilateral retinal detachment diagnosed by ultrasound	Case report
Schott et al 2011 USA	A 38-year-old woman with acute bilateral visual loss.	Case report		RD correctly diagnosed in right eye, left eye diagnosis on US was RD but actually vitreous detachment	Case report. The diagnoses in this case were difficult to confirm clinically.
Elia et al 2009 USA	A 79-year-old female with a 1 day history of left eye blindness	Case report		Retinal detachment diagnosed with ocular ultrasound	Training of emergency department practitioner not described Case report
Lewin et al, 2005, USA	35-year-old male with sudden visual loss from right eye	Case report		RD diagnosed with US	Case report

Comment(s)

Ocular ultrasound is a still a relatively new diagnostic tool for emergency physicians, and this is reflected in the fact that the eight studies I found included five case reports. Although the observational studies involved small sample sizes, ocular ultrasound was consistently found to be a very sensitive test. This was achieved with very little formal teaching; in one study the emergency practitioners received only a 30-min lecture on ocular ultrasound. The patients who were misdiagnosed in the studies all had vitreous haemorrhages and some had concomitant vitreous detachments. Acute vitreous haemorrhages typically appear minimally echogenic on US, but can become more echogenic and appear thickened with time, thus mimicking the appearance of a retinal detachment.

Editor Comment

ED, emergency department; RD, retinal detachment.

Clinical Bottom Line

Ocular ultrasound is a quick, accessible and accurate tool for the assessment of ocular pathology when performed by emergency physicians. Although this is a relatively new application for use of bedside ultrasound in the emergency department, the available evidence demonstrates that it is a sensitive test and that it is a skill that can be learned with minimal formal teaching.

References

1. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010;17:913–17.
2. Kahn A, Kahn AL, Corinaldi CA et al. Retinal detachment diagnosed by bedside ultrasound in the emergency department. Calif J Emerg Med 2005:6:47–51.
3. Blaivas M, Theodoro D, Sierzenski PR A study of bedside ocular ultrasonography in the emergency department. Academic Emergency Medicine 2002;9:791–799.
4. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. Journal of Emergency Medicine 2011;40:53–7.
5. Palma J, Schott E. Acute, simultaneous, bilateral rhegmatogenous retinal detachment diagnosed with bedside emergency ultrasound. The American journal of emergency medicine 2013;31:466.e3–5.
6. Schott ML, Pierog JE, Williams SR. Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss. The Journal of Emergency Medicine 2013;4:136–9.
7. Elia J, Borger R. Diagnosis of retinal detachment in the ED with ultrasonography. The Journal of Emergency Medicine 2009;6:47–51.
8. Lewin MR, Williams SR, Ahuja Y. Ultrasonographic diagnosis of retinal detachment in the emergency department. Ann Emerg Med 2005;45:97–8.