Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities

Steven L Propst,Jonathan M Kirschner,Christian C Strachan,Elisa J Sarmiento,Benton R Hunter,Laura M Menard,Steven K Roumpf

doi:10.1001/jamanetworkopen.2019.21460

Steven L Propst, Jonathan M Kirschner + Show 5 more

Open Access

https://doi.org/10.1001/jamanetworkopen.2019.21460

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Abstract

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

Highlights

Ophthalmologic emergencies account for approximately 1.3 million emergency department (ED) visits in the United States annually.[1]
This study suggests that emergency practitioner–performed ocular pointof-care ultrasonography (POCUS) is an accurate test to assess for retinal detachment in adults
Study Eligibility Criteria Studies assessing the diagnostic accuracy of POCUS to diagnose posterior chamber abnormalities in adults were included if they met the following 3 criteria: POCUS examinations were performed by emergency practitioner (EP), the diagnostic reference standard included formal ophthalmologic examination, and sufficient information was provided to create a 2 × 2 table for the test characteristics to diagnose at least 1 of our predefined posterior chamber abnormalities

Summary

Introduction

Ophthalmologic emergencies account for approximately 1.3 million emergency department (ED) visits in the United States annually.[1] Many such cases are secondary to trauma, and more than 40% of ED ocular conditions are emergent.[2,3] Diagnoses involving the external eye and anterior chamber can typically be made on the basis of history and physical examination alone. Several studies have demonstrated that emergency practitioner (EP)–performed ocular pointof-care ultrasonography (POCUS) can be used to diagnose retinal detachment, as well as other ocular emergencies such as vitreous hemorrhage or detachment, lens dislocation, intraocular foreign bodies, or globe rupture.[6,7,8,9,10,11,12,13] The use of POCUS to diagnose retinal detachment has garnered attention because of the time sensitivity of treating the detachment and the difficulty for nonspecialists in making the diagnosis with physical examination and fundoscopy

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