Danica Zold, DO MPH | EM/FM PGY4
Article:
Objective:
To determine if Emergency medicine physicians can use POCUS for early and accurate identification of retinal detachment, vitreous hemorrhage, and vitreous detachment.
Importance:
Early detection and distinction among these 3 common ocular diagnoses, helps lead to proper disposition of patients, faster treatment and therefore prevention of potential permanent vision loss.
Study:
A prospective, observational, multicenter, diagnostic study was performed across 2 academic and 2 county EDs in southern CA from Feb 2016- April 2018. The study enrolled a total of 225 patients with ocular symptoms and concern for retinal detachment, vitreous detachment or vitreous hemorrhage (blurry vision, vision loss, flashers, floaters); 18 years or older, without concern for ocular trauma or globe rupture.
Ocular POCUS was performed by 75 Emergency medicine attendings, residents (PGY1-4) and PA’s of variable experience. They were given a 30 minute lecture and 30 minute hands on scanning lesson for the key US findings associated with each of the 3 diseases.
Both the POCUS scanners and ophthalmologists were blind to one another’s findings, however physicians were not blind to the patient, their histories or other evident physical exam findings. Patients underwent ocular POCUS evaluation followed by ophthalmologic evaluation. Diagnoses were compared, with the definitive correct diagnosis determined by ophthalmologist evaluation.
Findings:
Of the 4 sites involved in the study, the prevalence of ocular disease was found to 36%.
Of the 225 patients, ophthalmologists diagnosed 20.8% with retinal detachment. Ocular POCUS correctly diagnosed 46 of these 47 patients, resulting in 96.9% sensitivity. POCUS correctly ruled out retinal detachment in 156 of the 176 cases, resulting in 88.1% specificity.
Ophthalmologists diagnosed 24% of patients with vitreous hemorrhage. Ocular POCUS diagnosed 46 of these 54 patients correctly, resulting in 81.9% sensitivity and 82.3% specificity.
Ophthalmologists diagnosed 15% of the patients with vitreous detachment. Although ocular POCUS was only able to identify 19 of the 34 patients correctly, leading to a 42.5% sensitivity, POCUS was able to rule out vitreous detachment in 178 of the 190 negative cases, resulting in 96.0% specificity.
Overall, POCUS has a >90% negative predictive value for all 3 of these ocular diseases. It appears however, that emergency medicine providers are best at ocular POCUS when diagnosing retinal detachment, with a 99% NPV, 64.5% PPV, and 90.6% accuracy.
Take Home Points:
EM providers using ocular POCUS are better at successfully ruling in the disease then definitively ruling out.
Ocular POCUS should not replace the role of an ophthalmologist, however EM practitioners can use POCUS as an adjunct to help accurately and reliably identify retinal detachment, vitreous hemorrhage, and vitreous detachment with statistical significance, expediting care and treatment for ocular disease in the Emergency room.