Tag: Retinal Detachment

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Case 64: Ocular emergencies: A case of macula-on retinal detachment seen on POCUS  

Theresa Jo Thomas , Akash Desai

Case: A 49-year-old female with a past medical history of type 1 diabetes on insulin and myopia presented to the emergency department for vision changes. The patient stated that three days ago she noticed “flashers” in the vision of her right eye which she described as “squiggly lines”. The patient stated that on the day of her presentation to the emergency department at 1100 she noticed the bottom half of her vision as “grayed out” when looking to the ground. She stated that the grey vision was not present when looking upwards. The patient denied trauma to the eye, recent illness, eye pain, or eye irritation.   

Vitals : BP 129/87 HR 99 RR 17 SpO2 100% T 97.2 F  

Physical Exam: 

HEENT: Bilateral pupils equal, round, and reactive to light. Bilateral eyes without conjunctival injection, no hyphema or hypopyon. No pain with extraocular movements and extraocular movements intact. No notable trauma to orbit, no orbital bruising or tenderness.    Visual acuity was measured as below:

  • OD 20/50 Uncorrected 
  • OS 20/25 Uncorrected 
  • OU 20/50 Uncorrected 
  • OD 20/50 Corrected 
  • OS 20/30 Corrected 

Given patient’s concerning presentation, a bedside ocular ultrasound was performed to help further differentiate the patient’s complaint. 

Figure 1. Ocular ultrasound. Detached retinal membrane (R). The membrane is shown to be attached at the macula (M), lateral to the optic nerve (ON) which can be identified due to its characteristic nerve sheath shadow in the far field of the image.  
Figure 2. Ocular ultrasound clip with evidence of retinal detachment with macula-on. Ultrasound performed with linear array transducer in the longitudinal plane. The detached hyperechoic, serpiginous membrane, in a vertical orientation, seen on the left side of the image in the posterior chamber is indicative of a retinal detachment. Notice here that the detachment edge begins lateral to the macula. Due to a temporary PACS connectivity issue at the time of scanning, the ultrasound images were documented via mobile device recording of the screen rather than direct export. This explains the presence of motion artifact and reduced image fidelity in the attached clip. 
Figure 3. Differentiating between retinal detachment, posterior vitreous detachment, and vitreous hemorrhage with POCUS.  Source: POCUS 101

ED Course  

Ophthalmology was urgently consulted for concern for macula-on retinal detachment on bedside ultrasound. The patient was seen in the ED by ophthalmology who confirmed the diagnosis of macula-on retinal detachment, and the patient was scheduled for retinal surgery to occur later the same day. The patient was instructed to maintain NPO status and was discharged in hemodynamically stable condition to present to surgery as scheduled later that day.   

Discussion  

This case highlights the utility of POCUS in the diagnosis of retinal detachment. The presentation can vary, with patients often reporting an acute painless loss of vision or flashes and floaters [2]. Additional differential diagnoses include vitreous hemorrhage and posterior vitreous detachment, both of which can be identified on ultrasound. Retinal detachment is an ophthalmological emergency, while vitreous hemorrhage and posterior vitreous detachment can typically be managed with urgent outpatient follow-up with ophthalmology [2]. Thus, the diagnosis of retinal detachment is a time-sensitive diagnosis. The diagnosis of retinal detachment is typically made with dilated direct and indirect fundoscopic exams.  

When performing ocular ultrasound for this purpose, the linear array transducer should be used to obtain both transverse and longitudinal views of the eye. The patient should be instructed to move the eye superiorly and inferiorly as well as horizontally while examining with ultrasound [3]. The finding of interest suggesting retinal detachment is the presence of a retinal flap [4].  If the membrane flap is attached in the posterior globe and does not cross the optic nerve, this is suggestive of retinal detachment. This is typically a thicker, more hyperechoic flap than what is seen with a vitreous detachment [3]. Vitreous detachments, on the other hand, can cross the midline and are not tethered to the optic disc [3]. Should the retinal detachment be visualized extending temporally from the base of the optic nerve, near the approximate location of the macula, it is suggestive of macula off retinal detachment [3].  Conversely, lack of visualization of a retinal flap in the area of the macula is suggestive of macula-on retinal detachment.  

Ocular POCUS has been shown to diagnose retinal detachment reliably and accurately in the emergency department [5]. The standard of care includes urgent ophthalmology consultation as this problem is typically surgically managed to maximize vision preservation. Of note, macula-on retinal detachments have far better visual prognosis than macula-off retinal detachments, highlighting the importance of POCUS in facilitating early detection and vision-saving intervention.  Specifically, in macula-on cases, timely repair offers an opportunity to preserve central vision before permanent loss occurs, highlighting the value of ultrasound in distinguishing macula-on from macula-off detachments. It has been shown that emergency physicians can reliably exclude vitreous hemorrhage and detachment when performing POCUS to evaluate for retinal detachment [2]. We demonstrate here a case of macula-on retinal detachment identified on POCUS by an emergency physician.    

  

References  

  1. POCUS 101. Ocular ultrasound pocket card [Internet]. POCUS 101; 2020 Aug [cited 2026 Jan 6]. Available from: https://pocus101.b-cdn.net/wp-content/uploads/2020/08/POCUS-101-Ocular-Ultrasound-Pocket-Card.pdf 
  2. 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 Apr 5;2(4):e192162. doi: 10.1001/jamanetworkopen.2019.2162. PMID: 30977855; PMCID: PMC6481597.   
  3. Situ-LaCasse E, Adhikari SR. Ocular emergencies. Sonoguide [Internet]. American College of Emergency Physicians; 2020 Aug 18 [cited 2026 Jan 6]. Available from: https://www.acep.org/sonoguide/advanced/ocular-emergencies 
  4. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010 Sep;17(9):913-7. doi: 10.1111/j.1553-2712.2010.00809.x. PMID: 20836770. 
  5. Vrablik ME, Snead GR, Minnigan HJ, Kirschner JM, Emmett TW, Seupaul RA. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med. 2015 Feb;65(2):199-203.e1. doi: 10.1016/j.annemergmed.2014.02.020. Epub 2014 Mar 27. PMID: 24680547.  

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          Case 55: Diagnosing Posterior Ocular Chamber Abnormalities with Point-of-Care Ultrasound

          Kevin Vo, MD; Rachna Subramony, MD

          Case Presentation:
          A 31-year-old male with no significant past medical history presented to the Emergency Department with bilateral blurry vision, left greater than right. He had been evaluated earlier that day by an optometrist and referred for concern of retinal detachment. The patient reported flashes and floaters of uncertain duration but denied eye pain, discharge, foreign body sensation, headache, or trauma.

          Vital Signs: BP 132/77 mmHg | HR 60 bpm | Temp 97.3°F | RR 16 | SpO₂ 99%

          Physical Examination:
          The patient was in no acute distress. Ocular exam revealed mild conjunctival injection bilaterally. Intraocular pressures were 17 mmHg OS and 13 mmHg OD. Fluorescein exam showed no corneal uptake. Neurologic exam was normal; the patient was alert and oriented ×3 without focal deficits. The patient reported a superior visual field deficit in the left eye.

          A bedside ultrasound was performed.

          Figure 1 (video) : Echogenic detached membrane visualized in the posterior chamber of the left eye

          Figure 2 (video): Detachment tethered to the optic nerve.

          Discussion: 

          Point-of-care ultrasound (POCUS) is a valuable adjunct for emergency physicians in evaluating posterior ocular abnormalities. While anterior and external ocular conditions can often be diagnosed through history and physical examination, posterior chamber visualization is frequently limited in the emergency department due to the lack of specialized ophthalmic equipment and suboptimal exam conditions.

          POCUS offers a noninvasive, rapid, and radiation-free imaging modality that can enhance diagnostic accuracy in the acute care setting. Meta-analyses and prospective studies have demonstrated POCUS sensitivity of 94–97% and specificity of 88–96% for detecting retinal detachment1,2,3. Given this high sensitivity, POCUS can serve as an effective rule-out tool when used in conjunction with ophthalmologic evaluation.

          Retinal detachment typically appears as an echogenic, undulating membrane tethered to the optic nerve, a finding considered diagnostic in multiple studies.1,5 In this case, the optic nerve was difficult to visualize in the same plane as the detached membrane, making it challenging to definitively distinguish retinal from posterior vitreous detachment (Figure 2). However, given the patient’s corresponding visual field deficits and characteristic sonographic findings, the likelihood of retinal detachment remained high.

          The use of POCUS for diagnosing vitreous detachment differs from its performance for retinal detachment. In one prospective study, sensitivity and specificity were 42.5% and 96% respectively.3 Another meta-analysis showed POCUS’s sensitivity to be 67% and specificity to be 90%. For other posterior eye pathologies, such as lens dislocation, foreign body, and globe rupture, sensitivity and specificity were high.1 The application of POCUS in this case was more suited for determining the presence of a retinal detachment and guiding the subsequent steps in management and further ophthalmologic assessment. The presence of vitreous detachment is difficult to rule out with the use of ultrasound alone. 

          Conclusion:
          This case demonstrates POCUS’s utility as an adjunct to ophthalmologic examination in the evaluation of posterior ocular pathology. Retinal detachment, which typically requires more urgent intervention than posterior vitreous detachment, can be rapidly identified using POCUS in the emergency setting. In this case, ophthalmology was consulted, and the patient subsequently underwent a left eye vitrectomy with perfluoro-octane (PFO) tamponade for treatment of his retinal detachment.

          References: 

          1.Propst SL, Kirschner JM, Strachan CC, et al. Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities. JAMA Network Open. 2020;3(2):e1921460. doi:https://doi.org/10.1001/jamanetworkopen.2019.21460 

          2.Gottlieb M, Holladay D, Peksa GD. Point‐of‐Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta‐Analysis. Carpenter CR, ed. Academic Emergency Medicine. 2019;26(8):931-939. doi:https://doi.org/10.1111/acem.13682 

          3.Lahham S, Shniter I, Thompson M, et al. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Network Open. 2019;2(4). doi:https://doi.org/10.1001/jamanetworkopen.2019.2162 

          4.Ocular Ultrasound Made Easy: Step-By-Step Guide - POCUS 101. POCUS 101. Published 2018. Accessed August 4, 2025. https://www.pocus101.com/ocular-ultrasound-made-easy-step-by-step-guide/#Posterior_Vitreou s_Detachment_PVD 

          5.Kim DJ, Francispragasam M, Docherty G, et al. Test Characteristics of Point‐of‐care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Theodoro DL, ed. Academic Emergency Medicine. Published online December 17, 2018. doi:https://doi.org/10.1111/acem.13454

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          Test Characteristics of Point of Care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department

          Background

          Retinal detachment (RD) is the final diagnosis for 3-4% of patients presenting to the Emergency Department (ED) with ocular complaints. Presenting symptoms most commonly include acute onset flashes and floaters, however, this presentation is not unique. The timely diagnosis and differentiation of RD from more common, benign, and similarly presenting processes, such as posterior vitreous detachment, is important in order to treat RD and prevent the sequela of permanent vision loss.

          Point of care ultrasound (POCUS) has been successfully employed in the diagnosis of retinal pathology with high degrees of success according to observed test characteristics (sensitivity 97%-100%; specificity 83-100%) in emergency medicine (EM) literature. The generalizability of this data is limited, however, due to study features, including the use of highly experienced sonographers, inconsistent scanning protocols, and poor reference standards. This investigation seeks to derive the test characteristics for POCUS in the diagnosis of RD when used by a heterogeneous population of emergency physicians (EPs).

          Test Characteristics of Point of Care Ultrasound for the Diagnosis of RetinalDetachment in the Emergency Department

          Clinical Question

          What are the test characteristics (sensitivity and specificity) of POCUS for the diagnosis of RD in patients presenting with chief complaint of flashes or floaters, when performed by a group of emergency physicians with varying degrees of ultrasound experience?

          Methods & Study Design

          • Design
            • Prospective study using a convenience sample of patients presenting to the ED with a chief complaint of flashes or floaters in visual fields
          • Population
            • Conducted at Vancouver General Hospital, an urban academic tertiary care center
          • Inclusion Criteria
            • Patients presenting with chief complaint of acute (7 days or less) onset flashes or floaters in one or both eyes between March 2015 and September 2016
          • Exclusion Criteria
            • Age younger than 19 years, known diagnosis of RD, exam compromised due to advanced cataract in the affected eye, ophthalmologic surgery on affected eye within prior two weeks
          • Intervention
            • EP performed ocular POCUS with high-frequency linear transducer
            • Scan performed in both transverse and longitudinal plane with dynamic assessment of posterior chamber (patient looking left/right and up/down)
            • Positive or negative interpretation for RD was recorded
            • Reference Standard
              • Patients were referred to an ophthalmology resident who performed non-blinded assessment including a complete dilated retinal exam
              • Patients were then seen by a retina specialist blinded to the ED POCUS within 1 week, or for patients with a retinal tear or RD diagnosis, within 1 day
            • Standardized training session for emergency providers
              • EM attendings (20), fellows (2), and residents (8) of varying ultrasound experience received a 1 hour lecture on the use of POCUS to detect RD
              • All participating EPs performed one practice scan on a healthy volunteers
          • Outcomes
            • Primary outcome: Accuracy of the EP diagnosis with respect to the reference standard, the retina specialist diagnosis
            • Test characteristics: sensitivity, specificity, diagnostic accuracy, LR+, and LR- 

          Results

          Flow of Patients Through Study

          Primary analysis

            • Sensitivity: 75% (95% CI 48-93%)
            • Specificity: 94% (95% CI 87-98%)
            • Diagnostic accuracy: 91% (95% CI 85-96%)
            • LR-positive: 12.4 (95% CI 5.4-28.3)
            • LR-negative: 0.27 (95% CI 0.11-0.62)

          Secondary analyses

            • Test characteristics by level of training
              • Residents and fellows: 100% sensitivity, 95% specificity
              • Attending physicians: 71% sensitivity, 94% specificity
            • Test characteristics by number of patients enrolled by EP
              • 1-2 patients enrolled: 80% sensitivity, 71% specificity
              • 3 or more patients enrolled: 73% sensitivity, 98% specificity

          Limitations

            • Insufficiently powered for the secondary analyses
            • Single program study limits generalizability
            • Prior ultrasound experience was not explicitly assessed
            • RD is not always classically presenting, starting with a population defined by classic symptoms may influence observed test characteristics

          Authors Conclusion

          “In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan in the ED performed by a heterogeneous group of providers after a one-hour POCUS didactic is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.”

          Our Conclusion

          This study demonstrates that emergency physicians of varying training levels and ultrasound experience can successfully employ POCUS in the diagnosis of RD after only a short training session. By incorporating POCUS into the workup of patients presenting with ocular complaints characteristic of RD, true pathology can be identified with high specificity. Appropriate care can then be mobilized expeditiously in these scan-positive patients in order to prevent the permanent vision loss associated with this condition.

          Indeed, a 74% sensitivity is too low for POCUS to reliably be utilized by a heterogeneous population of EPs as a tool to rule-out RD, especially given the consequences of a missed diagnosis. It would be reasonable practice, therefore, as the authors suggest, for all patients with new onset flashes and/or floaters to continue be referred for further ophthalmologic evaluation to definitively rule-out RD and other conditions at-risk for progression to RD. It should also be noted, however, that a trend towards increased specificity was observed amongst physicians who enrolled more patients in this study. Taken in context with test characteristics reported in prior literature, these findings may suggest that specificity can be improved upon with experience, and in the hands of a trained sonographer, POCUS may also be used as a tool to reliably rule-out RD.

          The Bottom Line

          Emergency providers can reliably use point-of-care ultrasound to diagnose retinal detachment with high specificity after a short, one-time training course, but must recognize the limitations of POCUS as a tool to rule-out RD in this setting, given a relatively low sensitivity when used for this purpose.

          Authors

          This post was written by Oretunlewa Soyinka, MS4 at UCSD. Review and further commentary was provided by Cameron Smyres, MD, Ultrasound Fellow at UCSD.

          References

          1 .  Hikichi T, Hirokawa H, Kado M, et al. Comparison of the prevalence of posterior vitreous
          detachment in whites and Japanese. Ophthalmic Surg 1995; 26:39-43.

          2.  Hollands H, Johnson D, Brox AC, et al. Acute-onset floaters and flashes: is this patient at
          risk for retinal detachment? JAMA 2009; 302:2243-9

          3.  Alotaibi AG, Osman EA, Allam KH, et al. One month outcome of ocular related
          emergencies in a tertiary hospital in Central Saudi Arabia. Saudi Med J 2011; 32:1256-60.

          4.  Mitry D, Charteris DG, Fleck BW, et al. The epidemiology of rhegmatogenous retinal
          detachment: geographical variation and clinical associations. Br J Ophthalmol 2010;
          94:678-84.

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          Case # 12: Bilateral Vision Loss

          A 45 year old male with poorly controlled DM presents with bilateral vision loss. His right eye vision acutely worsened 3 days ago with the sensation of a curtain moving back and forth across his visual field. Today his left eye vision acutely worsened with flashes and floaters occurring. He denies any trauma, headache, or new medications.

          Vitals: T 98.6 HR 90 BP 149/87  RR 16 O2 98% on RA

          A bedside ultrasound of the orbits is performed,  what is the next best step in management?

          Left Eye

          Left Eye

          Right Eye

          Right Eye

          Answer and Learning Points

          Answer

          The ultrasound clips demonstrate hypoechoic material in the orbits bilaterally, swirling around with subtle eye movement. This is consistent with bilateral vitreous hemorrhage. The diagnosis was discussed with the patient and he was referred to ophthalmology clinic for dilated eye exam in 24 hours.

          Learning Points

          Vitreous hemorrhage is a common diagnosis (though usually unilateral) seen in poorly controlled diabetes. The most frequent etiologies include proliferative diabetic retinopathy, posterior vitreous detachment, and ocular trauma, with trauma more common in patients under the age of 40. Since it is difficult to obtain  a good physical exam of the posterior aspects of the eye without a dilated exam, there is high utility in the use of point of care ultrasound in evaluating for acute pathology.  It can be used to distinguish vitreous hemorrhage and retinal detachment, which have significantly different prognoses and treatment pathways. To perform an ocular ultrasound, follow these steps:

            1. Prepare the patient by laying the bed backwards and having their face parallel to the ceiling,  supporting the patient's head and neck with a pillow or blanket.
            2. Place a tegaderm over the eye (optional). If you do, ensure there is no air between the tegaderm and the eyelid.
            3. Place the ultrasound gel on the tegaderm and prepare the linear probe with the gain turned almost all the way up (this will help you visualize both retinal detachment and vitreous hemorrhage.
            4. Stabilize your hand on the patient's nasal bridge or zygoma, with the probe marker to your left, and place the probe transverse on the orbit with minimal pressure being applied directly to the eye.
            5. Adjust the depth to ensure the optic nerve is just visualized at the bottom of the screen. The anterior chamber and lens should be used as visual landmarks to ensure you are in proper location. Next, have the patient look up, down , left and right (oculokinetic echography), to assess for any abnormalities in the posterior aspects of the eye.
            6. Repeat this technique with the probe marker pointed superiorly and have the patient again look in all directions.

          Retinal detachment: The common POCUS findings include a thin linear structure tethered to the optic nerve.  It flaps back and forth as the eye is moved giving it the appearance of “swaying seaweed”. This is an ophthalmologic emergency, especially if the macula is still attached,  the ophthalmologist should be immediately consulted.

          Vitreous hemorrhage: You will notice a diffuse mobile opacity often described as a “snow globe” that is exacerbated with moving the eye from side to side. If this is seen in a diabetic patient with floaters, there is a high likelihood that the diagnosis is a vitreous hemorrhage. These patients will still need follow up with ophthalmology for further management, but typically there will not be an emergent intervention.

          Author

          This post was written by Sam Frenkel, MD, PGY-2 UCSD EM. It was reviewed by Michael Macias, MD, Ultrasound Fellow at UCSD.

          References

            1. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010;17(9):913-7.
            2. Dawson, Mallin. Introduction to Bedside Ultrasound, Volume 2. 2013. Apple iBook.
            3. Kilker B, Holst J, Hoffmann B. Bedside ocular ultrasound in the emergency department. Eur J Emerg Med. 2014;21(4):246-253.
            4. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med. 2011;40(1):53-57. 

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