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Three Part Question

in [a patient with suspected retinal detachment] can [bedside ocular ultrasound be used] to [detect retinal detachment]

Clinical Scenario

A 60 year old male of African origin comes to emergency department with intermittent flashing lights and floaters for 24 hours. He refuses consent for pupil dilation as he intends to drive back home if discharged. Its not possible to gain a clear view of retina with ophthalmoscope. Can you use the bedside ultrasound with linear array probe to diagnose retinal detachment ?

Search Strategy

search strategy is HDAS database on NICE website. 1976 to December 2017. Database searched were Medline, EMBASE, CINAHL.
((Ultrasonography OR ultrasonics OR ultrasound OR sonography OR ocular ultrasound) AND (Retina OR Retinal OR Retinal detachment OR detached retina OR detachment) AND (Emergency department OR casualty OR ED OR ER OR A&E)

Search Outcome

In total 131 papers were identified using this search strategy out of which 5 papers were relevant to the search questions. Case reports found in the search were excluded from appraisal.

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 patients with visual loss and ocular pathology including trauma. CT scan used as gold standard. Ultrasound performed by Emergency physicians who have had minimal training of 1 h lecture and 1 h hands on.	prospective observational study	detection of ocular pathology with ultrasound	8 patients out of 61 with RD. 100% sensitivity and specificity	small number. convenience sample. no kappa value given. Power not calculated as no previous studies available.
Yoonessi et al 2010 USA	48 patients with less than 48 hour symptoms of ocular pathology. gold standard was set as final diagnosis from ophthalmologist. ultrasound performed by 15 different emergency physicians of different skill and experience levels	triple blinded prospective observational study	detetction of retinal detachment	18 out of 48 patients had RD. Sensitivity 100% (95% CI 78% to 100), Specificity 83% (95% CI 65% to 94%)	small sample size. very wide exclusion criteria.no kappa value given. wide confidence intervals
Shinar et al 2011 USA	92 patients convenience sample with ocular pathology. gold standard was final diagnosis by ophthalmologist. 31 different emergency physicians performed ultrasound after minimal training for ocular ultrasound	prospective observational study	detection of retinal detachment	29 out of 92 patients with RD. Sensitivity 6.5% (95% CI 82% to 100%), specificity 92.0% (95% CI 68% to 95%)	convenience sampling. wide confidence interval. no kappa value. power of study not calculated
Jacobsen et al 2015 USA	charts of 109 patients with suspected retinal detachment reviewed retrospectively. gold standard was final diagnosis by ophthalmologist. Reviewers were blinded to results of emergency ultrasound.	retrospective study	detection of RD with ocular ultrasound	34 out of 109 patients had RD. sensitivity 91% (95% CI 76-98) specificity 96% (95% CI 89-99)	retrospective study. one EP performed 35% of the ultrasound causing potential inflation bias. Ophthalmologist diagnosing as gold standard not blinded to EP ultrasound results
Vrablik et al 2014 USA	A systematic review and meta-analysis. 7771 unique citation found. 78 papers selected for full text review. 4 papers assesed for quality. 3 deemed to have low risk of bias	SYstematic review and Meta-analysis	accuracy of bedside ultrasound for detection of RD	range under the curve 0.943 to 1.0. summary area under the curve 0.957	total number of enrolled patients in 3 trials is 201. referral or spectrum bias could not be excluded.

Comment(s)

the use of bedside ultrasound for various pathologies is becoming increasingly common in emergency departments. Linear array probes are now being used for ocular ultrasounds to rule out ocular pathologies and measure ICP. With indirect ophthalmoscopy and slit lamp examinations for diagnosing retinal detachment being highly specialised skills, the prospective studies and systematic review clearly favours the use of ocular ultrasound by emergency physicians to detect retinal detachment.

Clinical Bottom Line

Bedside ocular ultrasound is a very useful adjunct to clinical assessment and examination in ruling out retinal detachmnet.

References

1. Blaivas et al A study of bedside ocular ultrasonography in the emergency department
2. Yoonessi et al Bedside ocular ultrasound for the detection of retinal detachment in the emergency department
3. Shinar et al Use of ocular Ultrasound for the evaluation of retinal detachment
4. jacobsen et al Retrospective review of ocular point-of-care ultrasound for detection of retinal detachment
5. Vrablik et al The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: A systematic review and meta-analysis