Post by Dr. Elias Youssef
Case: 55 year old male, no sig pmhx, comes in with unilateral right side visual loss that started approximately 1 hour prior to arrival while having forceful coughing episodes. Patient states that he feels as if a curtain is coming down his right eye and is obstructing his vision. Patient denies pain.
What is your DDx for Painless Visual Loss?
amaurosis fugax, retinal artery occlusions, central retinal vein occlusion, vitreous hemorrhage, ischemic optic neuropathies, posterior cerebrovascular accidents, and retinal detachment
Retinal detachment is an ocular emergency that can present to the emergency department. In the ED, it is often difficult to evaluate the retina because full evaluation requires dilatation of the pupil with mydriatic agents, a procedure that ED physicians do not perform on a regular basis. However, ED physicians are trained in point of care bedside ultrasound and this paper sheds light on our ever increasing capabilities to perform advanced bedside testing and early diagnosis in the emergency department.
Goal of the Study: The goal of the study was to assess the accuracy of ocular point-of-care ultrasound (POCUS) in diagnosing retinal detachment.
Type of Study: This was a retrospective study including residents and attendings trained in ocular ultrasound.
Results: They found a very high sensitivity and specificity (91% and 96%) when evaluating a patient for retinal detachment.
142 patients had a diagnosis made with point of care ultrasound in the emergency department and 109 of these patients had a diagnosis made by ophthalmology.
Of the 109 patients, 34 had a retinal detachment.
Bedside ultrasound identified 31 of the 34 patients with retinal detachment and correctly ruled out 72 of the 75 without retinal detachment
Conclusion: Bedside ultrasound in the emergency department has high sensitivity and specificity for detecting retinal detachment
How to perform Bedside Ocular US: Place a tegaderm over the patient’s closed eye and place copious gel over the tegaderm. Use the linear probe for the procedure. Make sure to place the probe on the surface of the gel and use your other fingers to brace your hand and hold the probe steady. (See the video.) Please keep in mind that a contraindication to this procedure is suspected globe rupture.
Identify the findings in the four images below.
Which image is normal? Image C. Note the empty hypoechoic posterior chamber. The anterior chamber and lens are very clearly seen.
Which image displays retinal detachment? Image D. The posterior chamber has two hyperechoic lines that appear to arise from the hypoechoic optic nerve sheath behind the posterior chamber. This is different than a vitreous detachment (Image A) in which the hyperechoic line appears to be floating in the posterior chamber with no attachment.
Which image displays vitreous hemorrhage? Image B. Echogenic material within the posterior chamber is the vitreous hemorrhage. When the patient moves the eye side to side, the echogenic material may swirl and rotate resembling clothes in a washing machine.