46 year old male without medical problems taking no medications presents for “black spots” in his right eye vision since 9 pm yesterday. No pain, trauma, or full vision loss. Had LASIK 15 years ago without any complications. No other complaints.
Negative review of systems.
Normal except for Eyes: PERRL, EOM intact; conjunctiva and sclera clear. VA: 20/20 bilaterally, no signs of corneal abrasion, IOP R 20 L 15
Bedside ultrasound shows the following:
- What do we see in these images?
- What are the two different types of retinal detachment that we can differentiate with ultrasound?
- Why is this differentiation important?
- What type of retinal detachment is demonstrated in this patient?
- What is the next best step in management?
- Retinal detachment
- Macula on, “mac-on,” and macula off, “mac-off.” (See descriptions below.)
- Mac-on detachments are an ophthalmologic emergency because vision can be preserved with rapid intervention, whereas mac-off detachments rarely have return of vision.
- Mac-on (see red arrow in the second image above)
- Emergent ophthalmology consult
- Physical Exam findings:
- Visual Acuity normal or mildly reduced
- Macula: flat
- US finding: Retina appears tethered to the optic nerve and remains attached to the area of the macula. (As seen in the second image above.) (The macula can be found by drawing a perpendicular line straight back from the lens.)
- An emergency as macula is still intact. Patients should be referred for surgery immediately in order to preserve the macula and prevent it from detaching and preventing visual loss.
- Physical Exam findings
- Visual acuity is severely reduced
- Macula is elevated
- US finding: Retina becomes tethered to the optic nerve and detaches from the macula giving a "V" shaped finding in the posterior aspect of the eye.
- Not an emergency as the macula is detached. Surgery can be scheduled for 1-2 weeks later.