Case
A 52 year old male, with a history of hypertension, presents to your emergency department with partial vision loss. He said that about five days ago he sneezed and noticed a curtain obscuring the outer part of his vision in the right eye. Over the next few days, it seemed to get worse, so he came in to get checked out. He denies any pain in the eye or headache. Visual acuity is 20/30 in the left eye and 20/100 in the right eye.
Externally, his eyes appear normal bilaterally:
He has a normal anterior chamber, without any signs of corneal damage on fluorescein exam.
You put the ultrasound on his right eye and see this:
Clinical Presentation
Painless, monocular loss of vision, usually without trauma
Might be accompanied by flashers or floaters
Patients may see a curtain-closing field cut
Risk factors: aging (more common in people over 50), previous retinal detachment or eye surgery or severe injury, nearsightedness, diabetic retinopathy, Marfan's disease, sickle cell disease, premature birth, pre-eclampsia
Physical Exam
Always perform a visual acuity test at triage
Full neurologic exam to rule out stroke, vessel occlusion, etc.
External eye exam and slit lamp exam will be normal
Retinoscopy (difficult to do in the ED without pupil dilation) will reveal a hazy gray retina with whitish folds - May have absent red light reflex
Ultrasound will be most revealing
Ultrasound
String-like object that anchors to the optic nerve (does not cross optic nerve) - Vitreous detachment will not anchor to optic nerve
Determine if the macula (lateral to the optic nerve) is affected or not - While both should be treated as ocular emergencies, macula on is considered more of an emergency because vision is partially spared and salvageable.
Treatment
Bed rest, elevate head of bed
Emergent ophthalmology consult and surgical intervention
References
Walker RA, Adhikari S. Eye Emergencies. Chapter 236. Tintinalli's emergency medicine: a comprehensive study guide. New York: McGraw-Hill; 2016.
Michael Prats, MD. Ocular POCUS of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment. Ultrasound G.E.L. Podcast Blog. Published on June 10, 2019. Accessed on January 06, 2020. Available at https://www.ultrasoundgel.org/70.
Lahham S, Shniter I, Thompson M, Le D, Chadha T, Mailhot T, Kang TL, Chiem A, Tseeng S, Fox JC. Point-of-care ultrasonography in the diagnosis of retinal detachment, vitreous hemorrhage, and vitreous detachment in the emergency department. JAMA Netw Open. 2019;2(4):e192162. doi: 10.1001/jamanetworkopen.2019.2162.