Case 53

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.

Physical exam:
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:

QUESTIONS

  1. What do we see in these images?
  2. What are the two different types of retinal detachment that we can differentiate with ultrasound?
  3. Why is this differentiation important?
  4. What type of retinal detachment is demonstrated in this patient?
  5. What is the next best step in management?

ANSWERS

  1. Retinal detachment
  2. Macula on, “mac-on,” and macula off, “mac-off.” (See descriptions below.)
  3. Mac-on detachments are an ophthalmologic emergency because vision can be preserved with rapid intervention, whereas mac-off detachments rarely have return of vision.
  4. Mac-on (see red arrow in the second image above)
  5. Emergent ophthalmology consult

Macula On

  • 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.

Macula Off

  • 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.

References:

http://rgw.com/patient-education/eye-diseases/retinal-detachment

https://www.hindawi.com/journals/joph/2015/821864/

https://maculacenter.com/eye-disease/retinal-detachment/