Images in Emergency Medicine
Article Outline
A 56-year-old man presented to the emergency department (ED) with a 2-day history of right eye and temporal pain. A fixed floater in the inferior temporal quadrant of his right eye gradually progressed curtainlike to midline, with a gross visual field deficit in that region. Along with hypertension and smoking, the patient had had right-eye cataract surgery. Physical examination revealed visual acuities of oculus uterque 20/20, oculus sinister 20/20, oculus dexter 20/30. Intraocular pressures for the right and left eye were, respectively, 18 and 9. Funduscopic examination was unrevealing. Head computed tomography, erythrocyte sedimentation rate, CBC, and electrolyte results were all normal. Ultrasonographic images of the affected and unaffected eye are shown (Figure 1, Figure 2).
Figure 1.
Ultrasonographic image of the right eye, showing an echogenic, concave line in the vitreous body of the eye.
Figure 2.
Ultrasonographic image of the left eye. Used with permission of Todd Baker, MD, Department of Emergency Medicine of Madigan Army Medical Center, Tacoma, WA.
Diagnosis
Retinal detachment
The images were obtained with a 5- to 10-MHz linear probe, with a closed-eye technique. The images observed from the patient’s ultrasonography are typical of retinal detachment. It will appear as an echogenic band suspended in the vitreous body of the eye.1, 2 Retinal detachment is a common cause of vision loss, and treatment includes urgent surgical repair. Helpful diagnostic hints for an accurate diagnosis include unilateral painless vision loss, described as a “curtainlike” appearance, sudden flashes of light, or floaters, and it can be associated with trauma. Visual acuity is variable, and visual field deficits correspond to the detachment location.3 The painful vision loss in this patient is an atypical presentation of retinal detachment. Regardless of the unclear presentation, ultrasonography was used to make a quick and accurate diagnosis. In 1957, the first published ultrasonographic diagnosis of retinal detachment was made by Oksala and Lehtinen.4 In a study done by Blaivas et al5 in 2002, emergency physicians used bedside ultrasonography to correctly diagnose 60 of 61 patients with acute vision changes, 9 of which were retinal detachments. Ocular ultrasonography is not the standard of care in the ED, but it can safely and effectively dispose a patient quickly to minimize time until definitive care.
References
- . Future applications for emergency ultrasound. [letter] Emerg Med Clin North Am. 2004;22:817
- . Beside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med. 2000;7:947–950
- . Opthalmology. In: Marx J, Kang C, Roberts J, et al. editor. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby; 2006;p. 1044–1065
- . Diagnostics of detachment of the retina by means of ultrasound. Acta Ophthalmol (Copenh.). 1957;35:461–467
- . A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9:791–799
For the diagnosis and teaching points, see page 95.To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.comThe opinions or assertions contained herein are the private views of the authors and not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense.
PII: S0196-0644(06)02621-7
doi:10.1016/j.annemergmed.2006.12.005
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
