Sonography in acute ocular pathology: a kaleidoscopic view

Feasibility of USG-Guided Objective Initial Assessment of Pupillary Size and Pupillary Reflexes Versus Clinical Examination in Patients With Altered Mental Status: A Cross-Sectional Study

BACKGROUND

Pupillary assessment is an important part of the neurological assessment which provides vital information in critically ill patients. However, clinical pupillary assessment is subjective. The ultrasound-guided pupillary examination is objective. There are limited pieces of literature regarding its use in assessing patients with altered mental status. So, we studied the extent of agreement of B-mode ultrasound with clinical examination for assessment of the pupillary size and reflex in patients with altered mental status.

OBJECTIVES

The primary objective was to determine the extent of agreement between clinical examination and ultrasound-based examination for assessing pupillary reflex and size in patients with altered mental status in two settings (trauma and non-trauma patients).

METHODS

Exactly 200 subjects (158 males, mean [range] age 43.56 [18-92 years]) with no history of partial globe rupture or dementia were included in this cross-sectional study from March 2019 to March 2020. B-mode ultrasound was performed with the subject's eyes closed using a 7-12 MHz linear probe and a standardized light stimulus. ICC score, paired t-test, kappa, Wilcoxon signed-rank test, and Bland-Altman plots were used for statistical analysis.

RESULTS

The clinical-USG agreement for pupillary light reflex examination (Pupillary Diameter [PD] at rest, after direct light stimulation [Dstim ] and consensual light stimulation [Cstim ]) was excellent (ICC, 0.93-0.96). The Kappa coefficient (0.74 ± 0.07) showed an agreement of 87.36% between clinical and USG examination for pupillary reflex (reactive or non-reactive).

CONCLUSION

USG-guided pupillary examination proves to be a better adjunct to neurological assessment in patients with altered mental status.

Emergency Ocular Ultrasound - Common Traumatic and Non-Traumatic Emergencies Diagnosed with Bedside Ultrasound

Point-of-care ocular ultrasound (POCOUS) in the ambulatory and critical care setting has become an invaluable diagnostic tool for patients presenting with traumatic or atraumatic vision and ocular complaints. Sonographic bedside evaluation is intuitive and easy to perform and can accurately diagnose a variety of pathologies. These include detachment or hemorrhage of the retina or vitreous, lens dislocation, retrobulbar hematoma or air, as well as ocular foreign bodies, infections, tumors, and increased optic nerve sheath diameter that can be assessed in the setting of suspected increased intracranial pressure. The ocular anatomy is easy to visualize with sonography, as the eye is a superficial structure filled with fluid. Over the last two decades, a large number of scientific publications have documented that POCOUS in emergent or critical care settings is an accurate diagnostic tool and expands and improves emergency diagnosis and management. This article will review POCOUS exam techniques as well as normal sonographic findings and common pathologies.

Impact of Emergency Medicine Point-of-Care Ultrasound on Radiology Ultrasound Volumes in a Single Pediatric Emergency Department

PURPOSE

Point-of-care ultrasound (POCUS) is growing, but few data exist regarding its effects on radiology ultrasound (Rad US) volumes. The authors studied changes in Rad US ordered by emergency medicine (EM) as POCUS began and grew at their pediatric hospital.

METHODS

This retrospective study included EM POCUS and EM-ordered Rad US volumes between 2011 and 2017, during three 2-year intervals: before POCUS, early POCUS, and expanded POCUS. Changes in overall Rad US and POCUS volumes per visit during these intervals were studied. Changes in skin and soft tissue infection (SSTI) US per SSTI visit, an examination performed diagnostically by both radiology and EM, were also assessed. Volume differences were examined using the Mann-Whitney U test (significance threshold, P < .05), and process control charts were used to identify nonrandom variations.

RESULTS

The study included 49,908 Rad US and 2,772 POCUS examinations during 647,890 emergency department visits. Rad US volumes per visit remained unchanged during early POCUS (P = .858) but increased with expanded POCUS (P < .005). A transient nonrandom increase in Rad US occurred as POCUS began. SSTI Rad US per SSTI visit significantly increased (P < .001) during early POCUS but did not change with expanded POCUS (P = .143). An SSTI management pathway in the emergency department before expanded POCUS may have affected ordering. Other variation occurred in proximity to practice changes and seasonal patterns.

CONCLUSIONS

Rad US overall and specifically for SSTI increased or remained stable during the introduction and growth of EM POCUS. Rather than decreasing Rad US, EM POCUS had a complementary role.

Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities: A Systematic Review and Meta-analysis

IMPORTANCE

Diagnosing posterior chamber ocular abnormalities typically requires specialist assessment. Point-of-care ultrasonography (POCUS) performed by nonspecialists, if accurate, could negate the need for urgent ophthalmologist evaluation.

OBJECTIVE

This meta-analysis sought to define the diagnostic test characteristics of emergency practitioner-performed ocular POCUS to diagnose multiple posterior chamber abnormalities in adults.

DATA SOURCES

PubMed (OVID), MEDLINE, EMBASE, Cochrane, CINAHL, and SCOPUS were searched from inception through June 2019 without restrictions. Conference abstracts and trial registries were also searched. Bibliographies of included studies and relevant reviews were manually searched, and experts in the field were queried.

STUDY SELECTION

Included studies compared ocular POCUS performed by emergency practitioners with a reference standard of ophthalmologist evaluation. Pediatric studies were excluded. All 116 studies identified during abstract screening as potentially relevant underwent full-text review by multiple authors, and 9 studies were included.

DATA EXTRACTION AND SYNTHESIS

In accordance with PRISMA guidelines, multiple authors extracted data from included studies. Results were meta-analyzed for each diagnosis using a bivariate random-effects model. Data analysis was performed in July 2019.

MAIN OUTCOMES AND MEASURES

The outcomes of interest were diagnostic test characteristics of ocular POCUS for the following diagnoses: retinal detachment, vitreous hemorrhage, vitreous detachment, intraocular foreign body, globe rupture, and lens dislocation.

RESULTS

Nine studies (1189 eyes) were included. All studies evaluated retinal detachment, but up to 5 studies assessed each of the other diagnoses of interest. For retinal detachment, sensitivity was 0.94 (95% CI, 0.88-0.97) and specificity was 0.94 (95% CI, 0.85-0.98). Sensitivity and specificity were 0.90 (95% CI, 0.65-0.98) and 0.92 (95% CI, 0.75-0.98), respectively, for vitreous hemorrhage and were 0.67 (95% CI, 0.51-0.81) and 0.89 (95% CI, 0.53-0.98), respectively, for vitreous detachment. Sensitivity and specificity were high for lens dislocation (0.97 [95% CI, 0.83-0.99] and 0.99 [95% CI, 0.97-1.00]), intraocular foreign body (1.00 [95% CI, 0.81-1.00] and 0.99 [95% CI, 0.99-1.00]), and globe rupture (1.00 [95% CI, 0.63-1.00] and 0.99 [95% CI, 0.99-1.00]). Results were generally unchanged in sensitivity analyses of studies with low risk of bias.

CONCLUSIONS AND RELEVANCE

This study suggests that emergency practitioner-performed ocular POCUS is an accurate test to assess for retinal detachment in adults. Its utility in diagnosing other posterior chamber abnormalities is promising but needs further study.

Imaging of Nontraumatic Orbital and Neuro-ophthalmological Emergencies

Emergency department (ED) visits for eye and vision-related concerns are common. In most cases, accurate diagnosis is made using clinical history and physical exam findings without the need for emergent imaging. When orbital imaging is performed in the ED, it is often in patients with orbital trauma where CT is used to assess for orbital fractures and associated injuries. However, CT or MR imaging can also be critical to appropriately diagnose and manage certain ED patients with nontraumatic eye and vision-related conditions. The purpose of this article is to review the imaging findings and differential diagnoses for nontraumatic orbital and neuro-ophthalmological emergencies from a practical, clinical perspective, based on a patient's typical presenting symptoms. The more commonly imaged clinical indications will be discussed including periorbital swelling, proptosis, eye pain, diplopia, and visual disturbances. In addition, rare but easily overlooked and clinically important diagnoses for the emergency radiologist to recognize will be highlighted.

Role Of Point Of Care Ultrasound In The Diagnosis Of Retinal Detachment In The Emergency Department

Ocular complaints represent up to 3% of all emergency department (ED) visits. These presentations can result in permanent vision loss if not promptly diagnosed and treated. Recently, point of care ultrasound (POCUS) has been investigated for the evaluation of ocular pathology in the ED. Multiple studies have investigated the role that ultrasound may play in the early diagnosis of these patients. Ocular ultrasound can be used to visualize the structures of the eye and evaluate for pathology such as retinal detachment, vitreous hemorrhage and vitreous detachment. This comprehensive review aims to present current evidence for the efficacy and reliability of ED ocular ultrasound use in the detection of retinal detachment and additional ocular pathologies.