Examiner Position in Ocular Point-of-Care Ultrasound: A Proposed Technique

BackgroundOcular point-of-care ultrasound (POCUS) is a fast and safe non-invasive procedure used to evaluate the structural integrity and pathology of the eye. Ocular POCUS can be used for evaluation of posterior chamber and orbital pathology, including retinal detachment, vitreous detachment or hemorrhage, foreign body, lens dislocation, and increased intracranial pressure.DiscussionThe purpose of this brief communication is to describe a technique for conducting an ocular POCUS that may in some cases be easier and more comfortable by adjusting the position of the sonographer relative to the patient.ConclusionsTo our knowledge, this proposed technique has not been described in previous literature and may result in greater comfort for both sonographer and patient.     

Use of Ocular Ultrasound for the Evaluation of Retinal Detachment

Background: Retinal detachment is an ocular emergency posing diagnostic difficulty for the emergency practitioner. Direct fundoscopy and visual field testing are difficult to perform and do not completely rule out retinal detachment. Ophthalmologists use ocular ultrasound to enhance their clinical acumen in detecting retinal detachments (RD), and bedside ultrasound capability is readily available to many emergency practitioners (EP). Study Objective: Our study sought to assess whether ocular ultrasound would be a helpful adjunct for the diagnosis of RD for the practicing EP. Methods: This was a prospective observational study with a convenience sample of patients. As part of a general course on emergency ultrasonography, practitioners received a 30-min training session on ocular ultrasound before beginning the study. Trained practitioners submitted ultrasound scans with interpretation on patients with signs and symptoms consistent with retinal detachment. Results: Thirty-one of the 72 practitioners trained submitted ocular ultrasound reports on patients presenting to the Emergency Department with concerns for retinal detachments. EPs achieved a 97% sensitivity (95% confidence interval [CI] 82–100%) and 92% specificity (95% CI 82–97%) on 92 examinations (29 retinal detachments). Disc edema and vitreous hemorrhage accounted for false positives, and a subacute retinal detachment accounted for the only false negative. Conclusion: These data show that trained emergency practitioners can use ocular ultrasound as an adjunct to their clinical assessment for retinal detachment.     

A Narrative Review of Common Uses of Ophthalmic Ultrasound in Emergency Medicine

BackgroundThe timely evaluation of ocular conditions in the emergency department (ED) can be difficult due to a general lack of specialized equipment, trained personnel, and the time-sensitive nature of emergent ocular conditions. Recently, the use of ocular point-of-care ultrasound (POCUS) has been shown to be particularly useful in the ED. POCUS can be used to promptly diagnose various ocular pathologies, which include ocular trauma, vitreous hemorrhage, central retinal artery occlusion, and retinal detachment.ObjectivesThis narrative review seeks to inform the reader of current literature regarding the use of POCUS for the assessment of various ocular emergencies in the ED. The goal of this review is to provide the emergency physician with succinct and up-to-date information and instruction regarding the current uses of POCUS for patients presenting with particular ocular emergencies. Ocular pathologies that are common (ocular trauma) or for which ultrasound is particularly useful (such as retinal detachment) are discussed. Other ocular pathologies are also briefly discussed, such as central retinal artery occlusion, which is a promising new application for ultrasound evaluation.DiscussionThere have been many studies that provide evidence for the utility of POCUS in the evaluation of trauma and other ocular pathologies, including vitreous hemorrhage, retinal detachment, and central retinal artery occlusion.ConclusionsOcular POCUS is a useful modality in the evaluation of acute ocular complaints in the ED. Emergency physicians should be aware of these findings and feel confident in the utility of ocular POCUS in the ED.     

A Study of Bedside Ocular Ultrasonography in the Emergency Department

The use of ocular ultrasonography for the evaluation of emergency patients has recently been described in the emergency medicine (EM) literature. There are a number of potential uses that may greatly aid the emergency physician (EP) and avoid lengthy consultation or other diagnostic tests. OBJECTIVE: To examine the accuracy of bedside ultrasonography as performed by EPs for the evaluation of ocular pathology. METHODS: This prospective, observational study took place in a high-volume, suburban community hospital with an EM residency program. All patients arriving with a history of eye trauma or acute change in vision were eligible to participate in the study. A 10-MHz linear-array transducer was used for imaging. All imaging was performed through a closed eyelid, using water-soluble ultrasound gel. Investigators filled out standardized data sheets and all examinations were taped for review. All ultrasound examinations were followed by orbital computed tomography or complete ophthalmologic evaluation from the ophthalmology service. Statistical analysis included sensitivity, specificity, and positive and negative predictive values. RESULTS: Sixty-one patients were enrolled in the study; 26 were found to have intraocular pathology on ultrasound. Of these, three had penetrating globe injuries, nine had retinal detachments, one had central retinal artery occlusion, and two had lens dislocations. The remaining pathology included vitreous hemorrhage and vitreous detachment. Emergency sonologists were in agreement with the criterion standard examination in 60 out of 61 cases. CONCLUSIONS: Emergency bedside ultrasound is highly accurate for ruling out and diagnosing ocular pathology in patients presenting to the emergency department. Further, it accurately differentiates between pathology that needs immediate ophthalmologic consultation and that which can be followed up on an outpatient basis.     

Pitfalls in the Use of Ocular Ultrasound for Evaluation of Acute Vision Loss

Background

Retinal detachment is a true medical emergency. It is a time-critical, vision-threatening disease often first evaluated in the Emergency Department (ED). Diagnosis can be extremely challenging and confused with other ocular pathology. Several entities can mimic retinal detachment, including posterior vitreous detachment and vitreous hemorrhage. Ocular ultrasound can assist the emergency physician in evaluating intraocular pathology, and it is especially useful in situations where fundoscopic examination is technically difficult or impossible. Accurate and rapid diagnosis of retinal detachment can lead to urgent consultation and increase the likelihood of timely vision-sparing treatment.

Objectives

This case demonstrates both the utility of ocular ultrasound in the accurate and timely diagnosis of retinal detachment and potential pitfalls in the evaluation of intraocular pathology in the ED.

Case Report

A 38-year-old woman presented with acute onset of bilateral visual loss that was concerning for retinal detachment. Rapid evaluation of the intraocular space was performed using bedside ocular ultrasound. Bedside ocular ultrasound correctly diagnosed retinal detachment in the right eye. Posterior vitreous detachment in the left eye was incorrectly diagnosed as retinal detachment.

Conclusion

This case illustrates the importance of bedside ocular ultrasound and highlights some of the pitfalls that can occur when evaluating for retinal detachment. Following is a discussion regarding methods to distinguish retinal detachment from vitreous hemorrhage and posterior vitreous detachment.     

Bedside Emergency Department Ultrasonography in the Evaluation of Ocular Pathology

The number of potential uses of emergency department (ED) ultrasound is growing. This brief report describes its use in two ED patients who presented with acute ocular pathology. The diagnoses were quickly made with ED ultrasound, and subsequently confirmed with more traditional methods of ocular evaluation.     

A Unique Case of Valsalva Retinopathy: Preretinal Hemorrhage Identified on Bedside Ultrasound

BackgroundEmergency physicians frequently evaluate patients with vision changes. The differential for this chief symptom is broad. We present a unique cause of a fixed scotoma that started while the patient was running sprints.Case ReportThe patient described a bright central scotoma that later became a dark oblique line across her central vision. This painless defect moved predictably with eye movements. Ocular ultrasonography was performed and revealed a well-demarcated hyperechoic lesion in the posterior segment of the right eye. There was no similar lesion found in her left eye. In consultation with ophthalmology, the patient's history and examination were consistent with valsalva retinopathy. To our knowledge, this is only the second published case of valsalva retinopathy/premacular hemorrhage identified on ocular ultrasonography in emergency medicine literature. In this article, we further expand on management and provide correlating fundoscopic images.Why Should an Emergency Physician Be Aware of This?Emergency physicians frequently evaluate patients with visual changes. Valsalva retinopathy is a rare cause of a visual scotoma that can be diagnosed through history and ultrasound. It often resolves over weeks to months without intervention. However, it does require urgent ophthalmologic evaluation to rule out peripheral retinal tears, which may require laser retinopexy or surgical management.     

Use of Ocular Point-of-Care Ultrasound in a Difficult Pediatric Examination: A Case Report of an Emergency Department Diagnosis of Retinoblastoma

BackgroundEye examination in distressed young children can be challenging in a busy emergency department. A full, detailed evaluation is, however, often needed in ocular emergencies.Case ReportA 2-year-old boy presented to our pediatric emergency department with refusal to open his left eye for 1 day. Eye examination was difficult and yielded limited findings, despite analgesia and parental facilitation. Under such circumstances, this might require sedation or forcibly everting the child's eyelids for the eye evaluation. A rapid ocular point-of-care ultrasound was performed, which revealed sonographic findings suggestive of a retinoblastoma in the left eye.Why Should an Emergency Physician Be Aware of This?The use of ocular point-of-care ultrasound facilitated the diagnosis of retinoblastoma in a child who was highly distressed and difficult to examine. Its use under such circumstances facilitated the patient's prompt evaluation and subsequent management.     

透明敷料与氯霉素滴眼液用于全身麻醉手术病人术中眼部保护的效果

[目的]探讨全身麻醉手术病人较好的眼部保护方法。[方法]将100例全身麻醉手术病人随机分为对照组和实验组。对照组采用湿生理盐水纱布遮盖病人双眼并用3M胶布固定,实验组采用氯霉素滴眼液与透明敷料配合轻拉眼睑的闭合粘贴法保护双眼。[结果]两组病人眼部不适感和并发症发生率比较,差异有统计学意义（P〈0.05或P〈0.01）。[结论]对全身麻醉手术病人采用透明敷料与氯霉素滴眼液配合轻拉眼睑的闭合粘贴法保护双眼,可有效减轻病人眼部不适、降低并发症发生率,是一种较为理想的术中眼部保护方法。     

An Inexpensive and Easy Simulation Model of Ocular Ultrasound That Mimics Normal Anatomy as Well as Abnormal Ophthalmologic Conditions

We have constructed a simple and inexpensive simulation model for the educational instruction of health care providers to detect normal and abnormal ocular conditions in the bedside emergency setting. Such a training model serves to increase the comfort level in performing ocular ultrasound examinations and can increase the accuracy of examination interpretation. Ophthalmologic examinations can be difficult in the emergency setting, and ultrasound has become a useful tool in the diagnosis of emergent ocular conditions.     

透明敷料与氯霉素滴眼液用于全身麻醉手术病人术中眼部保护的效果

[目的]探讨全身麻醉手术病人较好的眼部保护方法.[方法]将100例全身麻醉手术病人随机分为对照组和实验组.对照组采用湿生理盐水纱布遮盖病人双眼并用3M胶布固定,实验组采用氯霉素滴眼液与透明敷料配合轻拉眼睑的闭合粘贴法保护双眼.[结果]两组病人眼部不适感和并发症发生率比较,差异有统计学意义(P<0.05或P<0.01).[结论]对全身麻醉手术病人采用透明敷料与氯霉素滴眼液配合轻拉眼睑的闭合粘贴法保护双眼,可有效减轻病人眼部不适、降低并发症发生率,是一种较为理想的术中眼部保护方法.     

Cerebral Venous Thrombosis: An Uncommon Cause of Papilledema on Bedside Ocular Ultrasound

Background

Cerebral venous thrombosis (CVT) is a rare, difficult-to-diagnose form of venous thromboembolic disease and is considered a type of stroke. Its presentation is highly variable and may be easily confused for more common and less debilitating or life-threatening diagnoses such as migraine, seizure, or idiopathic intracranial hypertension.

实时三维超声透明模式在胆囊疾病中的应用

目的探讨实时三维超声透明模式在胆囊疾病中的应用价值.方法使用实时三维超声对89例胆囊疾病诊断.结果实时三维超声透明模式能够清晰显示胆囊病变的大小、数量、立体形态、胆囊壁回声,病变与胆囊壁的关系.结论实时三维超声透明模式对胆囊疾病的诊断更加准确.     

Ocular trauma in Turkey: A 2-year prospective study

This 2-year prospective study was conducted to identify those at risk for ophthalmologic emergencies, to define the risk factors and reasons for eye injuries, to analyze treatment options, and to compare findings with those of previous studies. A total of 203 patients (74% male, mean age 27.3±13.9 y, 51% right eye injuries, 44% left eye injuries, 5% bilateral injuries) with injury to 208 eyes who presented to the emergency department for treatment were included in this study. All patients were evaluated by an ophthalmologist, who completed a formal questionnaire. Information recorded included demographic data, details of the eye injury, whether eye protection was used, and the type, location, and mechanism of injury to the eye. Mechanism of injury was categorized as blunt, sharp, or a combination. The ophthalmologist reported the time that had passed between occurrence of injury and presentation for treatment. Each patient was examined by the ophthalmologist, and findings, diagnosis, and treatment were documented. Of treated patients, 93% were hospitalized, most of whom required surgical treatment. One hundred (48%) injuries were related to blunt trauma and 86 (41%) to sharp device trauma. Only 10 (4%) patients were wearing protective eyewear when injured. Ruptured globe was the most common diagnosis of hospitalized patients and the most frequent cause of this was corneal lesions; subconjunctival hemorrhage was the most common diagnosis among nonhospitalized patients. In this study, the leading cause of eye injury was workplace accidents, probably attributable to growing industrialization in the region. Ocular trauma continues to be an important health problem in Turkey. Investigators believe that with education about and use of proper eye protection, 90% of eye injuries could be prevented.     

The Tolerability of Lactated Ringer's Solution and BSS Plus for Ocular Irrigation with and without the Morgan Therapeutic Lens

Abstract. Objective: To evaluate two solutions, lactated Ringer's (LR) and a balanced salt solution (BSS Plus, Alcon Laboratories, Ft. Worth, TX), compared with normal saline solution (NSS), for ocular irrigation in healthy adult volunteers with and without the Morgan therapeutic lens (MTL). Methods: This was a prospective, double-blind, randomized study of healthy volunteers who were at least 18 years of age. Exclusion criteria included the use of analgesics within four hours of the study. A complete ophthalmologic examination was performed at baseline and at the completion of the study. Following randomization and prior to any intervention, baseline discomfort scores were obtained by means of a verbally administered, horizontal, 100-mm, unnumbered analog discomfort scale. Both eyes of each volunteer were irrigated simultaneously for 15 minutes, with additional discomfort scores being recorded every 5 minutes using the same 100-mm, unnumbered analog discomfort scale. A global evaluation to assess the method of irrigation and the solutions used for irrigation was completed by both the physician blinded to the treatment groups and the volunteers. The volunteers were continuously monitored for any adverse effects resulting from the irrigation solutions or MTL. Results: Sixty-three volunteers were recruited into the study, with 61 entered in the final analysis. Age and gender were balanced within each group. There was no significant difference in discomfort scores between the two groups; however, all discomfort scores decreased over time (p = 0.008). A lens-solution interaction was identified, with LR being the most tolerated when administered with the MTL. A statistically higher ocular pH difference was seen between the pre- and postirrigation readings for the control eye in volunteers irrigated with MTL (p = 0.046). Analysis of the global evaluations for each group revealed no difference in the distributions of physician and volunteer scores. No adverse event was reported in either group. Conclusion: There does not appear to be any difference in discomfort scores between the ocular irrigation fluids when used without the MTL. Overall, the use of the MTL appears well tolerated by healthy, adult volunteers. However, there does appear to be a significant lens-solution effect on volunteers' discomfort scores, with LR having significantly lower discomfort scores when used for ocular irrigation with the MTL. The authors conclude that the use of the MTL for ocular irrigation is well tolerated and recommend using LR as the irrigation solution for maximal patient comfort.     

高举平台结合3M透明敷料固定鼻胃管用于脑卒中患者的效果观察

目的探讨高举平台结合3M透明敷料固定鼻胃管用于脑卒中患者的应用效果。方法将2011年1月—2013年1月神经内科118例留置鼻胃管的脑卒中患者,按照抽签法分为对照组和观察组各59例,对照组采用传统的管道固定方法,观察组采用高举平台结合3M透明敷料固定方法,比较两组患者更换胶布间隔时间、更换胶布耗时、鼻胃管滑脱率、鼻胃管压疮发生率和患者舒适度。结果观察组患者更换胶布间隔时间较长,更换胶布耗时较短,鼻胃管滑脱率较低,差异均有统计学意义(P0.05),观察组患者压疮发生率低于对照组,舒适度评价高于对照组,差异均有统计学意义(P0.05)。结论高举平台结合3M透明敷料固定鼻胃管具有良好的固定效果,不易发生压疮,降低护理耗时和工作量,增加患者的舒适度,是一种较好的鼻胃管固定方法。     

不同透明贴预防留置针所致静脉炎的效果观察

[目的]探讨不同透明贴预防留置针所致静脉炎的效果。[方法]将102例使用留置针的住院病人分为观察组和对照组,观察组用康惠尔透明贴固定留置针,对照组用3M透明贴固定留置针,观察两组病人7d后静脉炎的发生情况。[结果]观察组、对照组静脉炎发生率分别为28.57%、71.74%,经比较差异有统计学意义（P〈0.01）。[结论]康惠尔透明贴预防留置针所致静脉炎的效果优于3M透明贴。     

实时超声造影对不超过2cm肝细胞癌定性诊断的临床研究

目的评估实时超声造影对≤2cm肝细胞癌的诊断价值。方法实时超声造影检查104个直径≤2．0cm的肝局灶性病变，造影剂为声诺维，成像技术采用对比脉冲序列。评估超声造影对其中49个肝细胞癌的诊断价值，并与普通超声比较。结果49个肝细胞癌病灶超声造影动脉期43（87．8％）个高增强，5个（10．2％）等增强，1个（2．0％）低增强。39（79．6％）个在门静脉期及延迟期增强消退为低增强。普通超声和超声造影定性诊断≤2cm肝细胞癌的敏感性、阴性预测值、准确性分别为28．6％（14／49）vs79．6％（39／49），P〈0．001；59．8％（52／87）vs90．7％（39／43），P=0．002；63．5％（66／104）vs86．5％（90／104），P〈0．001。结论实时超声造影比普通超声显著提高了对≤2cm肝细胞癌的诊断能力，但假阴性率偏高，应予注意。