Ocular ultrasound: Difference between revisions

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==Background==
*U/S has been well established in the ophtho literature but new advent to ED practice
==Indications==
*Acute/Subacute vision changes or loss
*Symptoms of increased ICP
*Suspect FB or globe rupture
*Trauma (assess for reactive pupils)
==Technique==
==Technique==
*Use vascular/linear probe
#Patient preparation
*Plenty of ultrasound gel to decrease amount of pressure needed to place on eye
#*Apply large transparent film dressing (such as Tegaderm) over the closed eye taking care not to create air bubbles between the film and skin surface
#*Deposit a copious amount of ultrasound gel to the film
#Select probe
#*Linear probe
#Location
#*Probe should be applied to the gel without creating significant pressure on the globe itself (especially in situations of suspected globe rupture)
#Landmarks
#*The round structure of the globe should be easily identified with the lens in the anterior section
#*Gain should be increased significantly to the point where echos are generating within the vitreous humor
#If needed, measurements of the optic nerve can be taken as still image


==Elevated ICP==
==Findings==
*Measure optic nerve 3mm posterior to the globe, from inner wall to inner wall
===Elevated ICP===
*Measure optic nerve 3mm posterior to the globe/papilla, from inner wall to inner wall
*Normal is <5mm<ref>Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected  by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med. 2003 Apr;10(4):376-81.</ref>
*Normal is <5mm<ref>Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected  by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med. 2003 Apr;10(4):376-81.</ref>
*U/S has a sensitivity of 95.6% and specificity of 92.3% for increased ICP<ref>Ohle R, McIsaac SM, Woo MY, et al. Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A Systematic Review and Meta-analysis. J Ultrasound Med. 2015; 34(7):1285-1294.</ref>


==Globe Rupture==
===[[Globe Rupture]]===
*Only perform if you can ensure that you do not put pressure on the globe
*Only perform if you can ensure that you do not put pressure on the globe
*Findings
*Findings
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**Vitreous hemorrhage
**Vitreous hemorrhage
**Buckling of the sclera
**Buckling of the sclera
* see [[Globe Rupture]]


==Intraocular Foreign Body==
===Intraocular Foreign Body===
*Bright, echogenic acoustic profile w/ associated shadowing or reverberation
*Bright, echogenic acoustic profile w/ associated shadowing or reverberation


==[[Retinal Detachment]]==
===[[Retinal Detachment]]===
*Echogenic undulating membrane in the posterior globe, protruding into the vitreous
*Echogenic undulating membrane in the posterior globe, protruding into the vitreous
*Evaluate with patient moving eye left/right
*Evaluate with patient moving eye left/right
*SN 97-100% and SP 83-100%<ref>Vrablik, ME, et al. The Diagnostic Accuracy of Bedside Ocular Ultrasonography for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. 2015; 65(2):199–203.e1.</ref>
*SN 97-100% and SP 83-100%<ref>Vrablik, ME, et al. The Diagnostic Accuracy of Bedside Ocular Ultrasonography for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. 2015; 65(2):199–203.e1.</ref>


[[File:Retinal detachment.jpg|thumb|Retinal detachment ultrasound]]
===[[Vitreous Hemorrhage]]===
 
==[[Vitreous Hemorrhage]]==
*Vitreous filled with multiple large echoes  
*Vitreous filled with multiple large echoes  
*Increasing the gain is helpful for detecting acute hemorrhages
*Increasing the gain is helpful for detecting acute hemorrhages


[[File:Vitreous hemorrhage.jpg|thumb|vitreous hemorrhage]]
==Images==
===Normal===
[[File:Ocular image.png|300px]]
 
#Eyelid
#Cornea
#Lens
#Ciliary bodies
#Lens
#Vitreous chamber
#Optic nerve
 
===Abnormal===
<gallery>
File:Retinal detachment.jpg|Retinal detachment ultrasound
File:Vitreous hemorrhage.jpg|Vitreous hemorrhage
File:ONSD.png|MEasuring optic nerve sheath diameter
</gallery>
 
==Pearls and Pitfalls==
*Use copious amount of gel to prevent the need for applying excessive pressure
*With the increase in gain to see the vitreous humor, there can be more artifact
*Many findings are more apparent with active eye movement
 
==Documentation==
===Normal Exam===
A bedside ultrasound was conducted to assess for signs of retinal detachment or vitreous hemorrhage with clinical indications of left/right sided vision changes. The anterior chamber, lens, and posterior chamber of the left/right eye was identified during active movement. There was no evidence of retinal detachment or vitreous hemorrhage found. There was no sonographic evidence of retinal detachment or vitreous hemorrhage.
===Abnormal Exam===
A bedside ultrasound was conducted to assess for signs of retinal detachment or vitreous hemorrhage with clinical indications of left/right sided vision changes. The anterior chamber, lens, and posterior chamber of the left/right eye was identified during active movement. There was a hyperechoic flap located in the anterior chamber/swirling debris in the posterior chamber. There was sonographic evidence of retinal detachment/vitreous hemorrhage.
 
==Clips==
===Normal===
<gallery>
File:Ocular - Pupil and Lense on US.gif|Lens with pupil visualized
File:Ocular - Normal but not enough gain.gif|Normal ocular exam but needs increased gain
</gallery>


==See Also==
===Abnormal===
[[Ultrasound (Main)]]
<gallery>
File:Ocular - Eyelid Edema.gif|Eyelid edema
File:Ocular - Vitreous and retinal detachment.gif|Combined vitreous and retinal detachment
File:Ocular - Retinal detachment.gif|Retinal detachment
File:Ocular - Retinal detachment - 2.gif|Retinal detachment
File:Ocular - Vitreous hemorrhage.gif|Vitreous hemorrhage
File:Ocular - Vitreous hemorrhage - 2.gif|Vitreous hemorrhage
File:Ocular - Retinal detachment and vitreous hemorrhage.gif|Combined retinal detachment and vitreous hemorrhage
</gallery>


==External Links==
==External Links==
*[http://www.ultrasoundpodcast.com/2012/04/episode-26-ocular-ultrasound-with-chris-fox/ Ultrasound Podcast - Chris Fox]
*[http://www.ultrasoundpodcast.com/2012/04/episode-26-ocular-ultrasound-with-chris-fox/ Ultrasound Podcast - Chris Fox]
*[http://www.ultrasoundvillage.com/imagelibrary/step3/?system=1&subsystem=16 Ultrasound Village - The Eye]
*[http://www.ultrasoundvillage.com/imagelibrary/step3/?system=1&subsystem=16 Ultrasound Village - The Eye]
==See Also==
[[Ultrasound (Main)]]
[[Retinal detachment]]
[[Vitreous hemorrhage]]
[[Posterior vitreous detachment]]


==Video==
==Video==
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<references/>
<references/>


[[Category:Ultrasound]]
[[Category:Radiology]]
[[Category:Ophthalmology]]
[[Category:Ophthalmology]]
[[Category:Radiology]]
[[Category:Ultrasound]]

Revision as of 19:26, 16 June 2016

Background

  • U/S has been well established in the ophtho literature but new advent to ED practice

Indications

  • Acute/Subacute vision changes or loss
  • Symptoms of increased ICP
  • Suspect FB or globe rupture
  • Trauma (assess for reactive pupils)

Technique

  1. Patient preparation
    • Apply large transparent film dressing (such as Tegaderm) over the closed eye taking care not to create air bubbles between the film and skin surface
    • Deposit a copious amount of ultrasound gel to the film
  2. Select probe
    • Linear probe
  3. Location
    • Probe should be applied to the gel without creating significant pressure on the globe itself (especially in situations of suspected globe rupture)
  4. Landmarks
    • The round structure of the globe should be easily identified with the lens in the anterior section
    • Gain should be increased significantly to the point where echos are generating within the vitreous humor
  5. If needed, measurements of the optic nerve can be taken as still image

Findings

Elevated ICP

  • Measure optic nerve 3mm posterior to the globe/papilla, from inner wall to inner wall
  • Normal is <5mm[1]
  • U/S has a sensitivity of 95.6% and specificity of 92.3% for increased ICP[2]

Globe Rupture

  • Only perform if you can ensure that you do not put pressure on the globe
  • Findings
    • Decrease in size of globe
    • Anterior chamber collapse
    • Vitreous hemorrhage
    • Buckling of the sclera

Intraocular Foreign Body

  • Bright, echogenic acoustic profile w/ associated shadowing or reverberation

Retinal Detachment

  • Echogenic undulating membrane in the posterior globe, protruding into the vitreous
  • Evaluate with patient moving eye left/right
  • SN 97-100% and SP 83-100%[3]

Vitreous Hemorrhage

  • Vitreous filled with multiple large echoes
  • Increasing the gain is helpful for detecting acute hemorrhages

Images

Normal

Ocular image.png

  1. Eyelid
  2. Cornea
  3. Lens
  4. Ciliary bodies
  5. Lens
  6. Vitreous chamber
  7. Optic nerve

Abnormal

  • Retinal detachment ultrasound

  • Vitreous hemorrhage

  • MEasuring optic nerve sheath diameter

Pearls and Pitfalls

  • Use copious amount of gel to prevent the need for applying excessive pressure
  • With the increase in gain to see the vitreous humor, there can be more artifact
  • Many findings are more apparent with active eye movement

Documentation

Normal Exam

A bedside ultrasound was conducted to assess for signs of retinal detachment or vitreous hemorrhage with clinical indications of left/right sided vision changes. The anterior chamber, lens, and posterior chamber of the left/right eye was identified during active movement. There was no evidence of retinal detachment or vitreous hemorrhage found. There was no sonographic evidence of retinal detachment or vitreous hemorrhage.

Abnormal Exam

A bedside ultrasound was conducted to assess for signs of retinal detachment or vitreous hemorrhage with clinical indications of left/right sided vision changes. The anterior chamber, lens, and posterior chamber of the left/right eye was identified during active movement. There was a hyperechoic flap located in the anterior chamber/swirling debris in the posterior chamber. There was sonographic evidence of retinal detachment/vitreous hemorrhage.

Clips

Normal

  • Lens with pupil visualized

  • Normal ocular exam but needs increased gain

Abnormal

  • Eyelid edema

  • Combined vitreous and retinal detachment

  • Retinal detachment

  • Retinal detachment

  • Vitreous hemorrhage

  • Vitreous hemorrhage

  • Combined retinal detachment and vitreous hemorrhage

External Links

See Also

Ultrasound (Main) Retinal detachment Vitreous hemorrhage Posterior vitreous detachment

Video

{{#widget:YouTube|id=A0gQmqWcIn8}}

References

  1. ↑ Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med. 2003 Apr;10(4):376-81.
  2. ↑ Ohle R, McIsaac SM, Woo MY, et al. Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A Systematic Review and Meta-analysis. J Ultrasound Med. 2015; 34(7):1285-1294.
  3. ↑ Vrablik, ME, et al. The Diagnostic Accuracy of Bedside Ocular Ultrasonography for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. 2015; 65(2):199–203.e1.
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