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.     

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.     

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 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.     

Unique Method of Ocular Ultrasound Using Transparent Dressings

Background

Utilizing bedside ocular ultrasound to aid in diagnosing pathology such as retinal detachment, lens disruption, ocular foreign bodies, or increased intracranial pressure is becoming more pervasive in the Emergency Department. To eliminate an air interface, one must apply ultrasound gel between the patient's skin and the probe. In ocular ultrasound, this practice results in discomfort for the patient as gel seeps into their eyes. To limit patient discomfort, many physicians do not apply a sufficient amount of gel for the examination. This can result in decreased image quality and may cause the ultrasonographer to apply greater pressure to the eye to obtain a satisfactory image. This can be harmful to patients with a ruptured globe and may also be painful to the patient.

Discussion

Traditionally, the first step in ocular ultrasound is to place a generous amount of water-soluble ultrasound gel on the eyelid to eliminate the air interface. The authors promote a different and simple technique. A transparent dressing is placed over a closed eye. A generous amount of ultrasound gel is applied to the dressing. A linear ultrasound probe is then placed on the gel and a standard ultrasound scan is obtained. Transparent dressings, which are used as sterile coverings for i.v. sites, have been found to allow satisfactory ultrasound transmission. These products remove the air interface between the eyelid and the dressing. This allows ultrasound gel to be placed on the transparent dressing and not directly on the eyelid, potentially eliminating discomfort for the patient, and creating an easier cleanup. Because a generous amount of ultrasound gel is applied, the ultrasonographer is able to apply minimal pressure on the eye to complete the study, which may decrease harm to the patient's eye. When finished, the transparent dressing is removed. There is no cleanup or patient irritation.

Conclusion

This article demonstrates a unique method of ocular ultrasound. The technique can be easily incorporated into emergency bedside ocular ultrasound.     

间质混浊眼视网膜脱离的超声诊断

目的 本文总结了因间质浑浊而要求B超检查,并经临床最后诊断确认为视网膜脱离(包括手术及各种眼底镜、三面镜随访检查结果。其中有27例行巩膜透热电凝术。)的60只眼球,并对其超声图像特征进行了分析。方法 美国产RT—3600,BIOSOUN6D—AU4超声诊断仪,线阵探头,频率7.5～10.0MHz。病人取仰卧位,闭眼,探头涂耦合剂直接置于眼皮上,多切面、多角度动态扫查。结果 全组60只眼中,超声诊断为视网膜脱离的有59只眼,根据其声像图特点可分为三类:一、视网膜局部脱离(39只眼),二、视网膜全脱离(14只眼),三、视网膜全脱离伴脉络膜脱离(6只眼)。超声诊断与临床最后诊断的符合率为98.3％(59/60)。结论 根据超声图象中眼球玻璃体内线状回声光带的不同形态可大致判断视网膜脱离的程度,为视网膜脱离的临床诊断、手术方式、疗效观察等提供有用的信息。     

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.     

Ultrasonographic assessment of paediatric ocular emergencies: A tertiary eye hospital based observation

BACKGROUND: The purpose of this study is to assess the utility of ocular ultrasound B scan in the emergency at the first point of care for detecting posterior segment and orbital pathologies in cases of paediatric ocular emergencies.METHODS: A prospective observational study involving 122 paediatric patients presenting to eye emergency over a period of ninety days were assessed with ultrasonography for the posterior segment as well as orbital pathology whenever indicated. The ocular ultrasound was performed gently over closed eyelids.RESULTS: Posttraumatic globe injuries were the most common indication for posterior segment evaluation, which constituted 80 (65.57%) eyes. Among these 52 patients had an anechoic posterior segment and 28 patients had variable findings such as vitreous haemorrhage (8.19%), retinal detachment (6.55%), choroidal detachment (4.91%), posteriorly dislocated clear lens (0.81%) and retained intraocular foreign body (5.73%). Non-traumatic cases constituted around 42 (34.42%) eyes, which included corneal ulcer (7.37%), retinoblastoma (6.55%), endophthalmitis (4.91%), extra-ocular muscle cysticercosis (4.91%), orbital cellulitis (4.09%), periocular haemorrhage (2.45%), proptosis(1.63%), paediatric cataract (1.63%) and cryptophthalmos (0.81%). No adverse events of performing the ultrasound was noted.CONCLUSION: First point ultrasonography in paediatric ocular emergencies is a cheap, portable and an effective tool in the assertion of significant posterior segment and orbital diseases.     

Ocular manifestations of COVID-19: facts and figures from a tertiary care center

IntroductionCOVID-19 patients presenting with ocular manifestations are from 0.8% to 32% of patients seen in the ED. The available literature is scarce regarding COVID-19 patients presenting with ocular manifestations from the Middle Eastern region.PurposeThis study aims to report the incidence of ocular signs and symptoms in COVID-19 patients and find any correlation between the occurrence of ocular manifestations and patients’ comorbidities.MethodsAll patients having the primary diagnosis of COVID-19 infection and concurrent ocular manifestations on admission to our tertiary COVID-19 health care centre were included in the study. The patient’s demographic data, comorbidities, and type of ocular manifestations were recorded from the patients’ health records retrospectively.ResultsIn our study, 39 (7.8%) patients presented with ocular manifestations. The majority of COVID-19 patients were male, and 200 (20%) patients had a history of other comorbidities. The majority of our patients had hyperaemia (13 [33.3%]), followed by eye pain (9 [23.1%]), epiphora (8 [20.5%]), burning sensation (4 [10.3%]), and photophobia (2 [5.1%]) patients. There was no statistically significant difference in the occurrence of ocular manifestations and patients’ gender or comorbidities (p > .05).ConclusionThe occurrence of ocular manifestations was lower compared to the present literature. There was no significant association between the occurrence of ocular manifestations and the patient’s gender or comorbidities.     

Can emergency physicians accurately distinguish retinal detachment from posterior vitreous detachment with point-of-care ocular ultrasound?

Study objective

There is significant overlap between the symptoms of patients presenting with retinal detachment (RD) and posterior vitreous detachment (PVD). Urgency to obtain consultation and treatment are dependent on the ability to accurately distinguish these two conditions. The objective of this study was to determine the ability of emergency physicians to differentiate RDs from PVDs using point-of-care (POC) ocular ultrasound.

Migraine and ocular pain in "glaucoma suspect"

A relationship between glaucoma and migraine has been hypothesized by some authors, but not confirmed by others. We studied the prevalence and features of migraine and ocular pain in 460 "glaucoma suspect" patients (with ocular hypertension, but without optic disc and visual field abnormalities) and 460 controls. A higher prevalence of migraine was found in patients (13%), particularly in women (17%), than in controls (7%). At the time of the interview, migraine was still active in 68% of the patients and had decreased in the remaining 32% (prevalently those not being treated for ocular hypertension), whereas it had ceased in 52% of controls. Attacks of "ocular pain" of mild and moderate intensity were found to occur in 51% of the patients with both "glaucoma suspect" and migraine, in almost all who were not taking treatment for ocular hypertension. "Ocular pain" was time-related to the history of glaucoma. Changes in intraocular pressure may play a role in the interaction between "glaucoma suspect", migraine, and ocular pain.     

619例眼肿瘤临床病理分析

目的：研究近五年来眼肿瘤的临床病理类型，为临床提供诊断和治疗依据。方法：对华西医院眼病理室2003年1月-2008年1月间所检查的619例眼部肿瘤资料进行回顾性分析。结果：良性肿瘤374例，恶性肿瘤245例。按取材的解剖部位分：眼睑肿瘤218例，眼表肿瘤134例，眼球内肿瘤69例，眼眶肿瘤198例。结论：对眼肿瘤进行临床和病理分析有利于临床诊断和处理。     

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.     

Patient satisfaction and diagnostic accuracy with ultrasound by emergency physicians

In recent years, there has been considerable interest and controversy concerning the performance of ultrasound by emergency physicians (ED Sono), but patient satisfaction with ED Sono has not been well studied. The primary purpose of this investigation was to assess the level of patient satisfaction with ED Sono and to compare satisfaction with ED Sono with ultrasound by the Medical Imaging Department (MI Sono). A secondary objective was to assess the accuracy of ED Sono at our facility. During a 5-month period, which included the startup phase of a program for ED Sono, emergency physicians prospectively identified patients who were candidates for ultrasound as a part of their workup. Patients were contacted by telephone after their ED visit and asked to rate satisfaction on a 0 to 10 scale for various aspects of their care, including the ultrasound if one was done. The accuracy of ED Sono was determined by comparing ED ultrasound interpretations with surgical pathology, repeat imaging studies, or clinical follow-up. Two hundred forty patients were entered into the study, and 186 (78%) responded to the satisfaction survey. Satisfaction ratings were similarly high for ED Sono (mean, 8.9; 95% Cl, 8.6 to 9.2) and for MI Sono (mean, 8.8; 95% Cl, 8.2 to 9.4). Eighteen percent of ultrasounds performed by emergency physicians were indeterminate. Excluding indeterminate scans and scans for which confirmation was not possible, the accuracy of ED Sono was 99.1% (95% Cl, 95.1% to >99.9%). We conclude that during the startup phase of our ED Sono program, patient satisfaction was high, and the error rate was very low.     

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. OBJECTIVES: The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. METHODS: The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. CONCLUSIONS: Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.     

儿童眼化学烧伤的护理体会

目的探讨儿童眼化学烧伤的护理特点及效果。方法总结15例儿童眼化学烧伤的护理体会。结果15例病人13例视力提高,无1例出现并发症。结论及时彻底冲洗结膜囊,细致的病情观察及心理护理,加强儿童眼化学烧伤的预防宣传是护理的重要内容。     

18例眼部神经纤维瘤的临床病理分析

目的：探讨眼部神经纤维瘤的临床和病理特征,提高临床诊断水平。方法：回顾性分析我院1980年1月至2002年12月手术切除并经病理证实为眼部神经纤维瘤的18例患者的病例资料。结果：单发于眼部者12例12只眼,合并神经纤维瘤病者6例7只眼。最好发的部位是眼睑皮下及眼眶,临床表现为受累部位的占位性病变及累及相关组织的表现。局限型6例,弥漫型3例,丛状型9例。6例丛状型合并神经纤维瘤病,其中4例有全身牛奶咖啡斑。所有病例均行手术治疗,术后7例治愈,其余未痊愈或复发,4例患者行两次以上手术。所有病例均经组织病理学检查确诊。结论：眼部神经纤维瘤伴发神经纤维瘤病者临床易于诊断,单发于眼部的神经纤维瘤主要依靠病理检查确诊。目前治疗还无最佳方法,手术切除应综合考虑,尤其是复发的问题。     

The association between operator confidence and accuracy of ultrasonography performed by novice emergency physicians

The variable accuracy of emergency department (ED) ultrasound described in the literature has limited its utility as the sole imaging modality in critical decision making. Although ultrasound accuracy is highly dependent upon the technical abilities of the operator and conditions unique to each patient, no previous study of ED ultrasound has included estimates of operator confidence. This prospective observational study explores the association between operator confidence and the accuracy of ED ultrasound. Ultrasound was not performed in our ED until a formal training module was instituted. Patients were enrolled prospectively for the first year following the training module if they underwent one of the following ultrasound studies: abdominal examination for intraperitoneal fluid, right upper quadrant examination for gallstones, renal examination for hydronephrosis, pelvic examination for intrauterine pregnancy, abdominal examination for aorta diameter > 3 cm, or cardiac examination for pericardial fluid. In addition, formal ultrasound, computed tomography, magnetic resonance imaging, or an invasive procedure was required as a "gold standard" for each patient. Operators recorded their interpretation of the ED ultrasound and rated their confidence with the analysis before the formal imaging study or procedure. Test performance characteristics for each examination type and for all studies together were determined. The association between operator confidence and accuracy was explored using logistic regression and by determining test performance characteristics with patients stratified by confidence value. A total of 276 ED ultrasound studies were included. There were no significant differences in accuracy between ED attendings and residents. Overall accuracy, sensitivity, specificity, LR+, and LR- were 90%, 92%, 86%, 6.8, and 0.09, respectively. With confidence scores of 9 or 10 (n = 113), these values improved to 96%, 99%, 90%, 9.6, and 0.01, respectively. Logistic regression revealed an association between confidence and ED ultrasound accuracy (p < 0.001). It is concluded that a significant association exists between operator confidence and the accuracy of ED ultrasound. High confidence values are associated with clinically useful test performance characteristics.     

眼挫伤继发青光眼的危险因素及治疗对策

目的探讨眼挫伤继发青光眼的危险因素及其治疗对策。方法选取2006年12月至2011年11月就诊的眼挫伤继发青光眼患者20例,分析其发病原因、治疗方法及治疗效果。结果在20例眼挫伤继发青光眼患者中,前房积血14例（70.00%）;房角挫伤4例（20.00%）;晶状体移位2例（10.00%）。经手术和药物治疗后,眼压控制正常者18例（90.00%）。结论前房积血、房角挫伤、晶状体移位是眼挫伤继发青光眼的危险因素;不同原因所致的眼挫伤继发青光眼所选择的治疗方法也不同,而手术时机是影响治疗效果的重要因素。     

白内障超声乳化术后高眼压患者的护理

目的探讨白内障超声乳化术后高眼压患者的护理方法。方法回顾性分析2009年3-12月某院行白内障超声乳化术276例患者的临床资料。结果 276例患者中有15例患者术后发生高眼压,经过合理治疗和护理干预,15例患者3d内均恢复正常眼压。结论有效的护理干预可以避免白内障超声乳化术后高眼压导致的永久性视功能损害。