The use of bedside ultrasound in diagnosing retinal detachment in Emergency Department.
Date First Published:
September 25, 2013
Last Updated:
April 30, 2014
Report by:
Dr J WIlkinson, ST8 Emergency Medicine/Intensive Care Medicine (Royal Blackburn Hospital)
Search checked by:
Dr Laith Sultan,, Royal Blackburn Hospital
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
Search Details:
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
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
Outcome:
In total 58 papers were identified using this search strategy, of which 8 were relevant to my clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Yoonessi R, Hussain A, Jang TB. 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 |
| Retinal detachment diagnosed by bedside ultrasound in the emergency department. Kahn A, Kahn AL, Corinaldi CA 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 | |
| A study of bedside ocular ultrasonography in the emergency department. Blaivas M, Theodoro D, Sierzenski PR 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 |
| Use of ocular ultrasound for the evaluation of retinal detachment. Shinar Z, Chan L, Orlinsky M. 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. |
| Acute, simultaneous, bilateral rhegmatogenous retinal detachment diagnosed with bedside emergency ultrasound. 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 | |
| Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss. Schott ML, Pierog JE, Williams SR. 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. | |
| Diagnosis of retinal detachment in the ED with ultrasonography. Elia J, Borger R. 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 |
|
| Ultrasonographic diagnosis of retinal detachment in the emergency department. Lewin MR, Williams SR, Ahuja Y. 2005, USA | 35-year-old male with sudden visual loss from right eye | Case report | RD diagnosed with US | Case report |
Author Commentary:
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.
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:
- Yoonessi R, Hussain A, Jang TB.. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department.
- Kahn A, Kahn AL, Corinaldi CA et al.. Retinal detachment diagnosed by bedside ultrasound in the emergency department.
- Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department.
- Shinar Z, Chan L, Orlinsky M.. Use of ocular ultrasound for the evaluation of retinal detachment.
- Palma J, Schott E.. Acute, simultaneous, bilateral rhegmatogenous retinal detachment diagnosed with bedside emergency ultrasound.
- Schott ML, Pierog JE, Williams SR.. Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss.
- Elia J, Borger R.. Diagnosis of retinal detachment in the ED with ultrasonography.
- Lewin MR, Williams SR, Ahuja Y.. Ultrasonographic diagnosis of retinal detachment in the emergency department.