{"id":1193,"date":"2018-01-20T00:58:26","date_gmt":"2018-01-20T00:58:26","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=1193"},"modified":"2020-07-21T23:58:30","modified_gmt":"2020-07-21T23:58:30","slug":"ocular-us","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/01\/20\/ocular-us\/","title":{"rendered":"Case # 12: Bilateral Vision Loss"},"content":{"rendered":"
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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\u00a0moving 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.<\/p>\n

Vitals: T\u00a098.6 HR\u00a090 BP 149\/87\u00a0 RR\u00a016 O2 98% on RA<\/p>\n

A bedside ultrasound of the orbits is performed,\u00a0 what is the next best step in management?<\/p>\n<\/div>\n<\/div>\n<\/div>\n

\n
\n
\"Left<\/a>

Left Eye<\/p><\/div>\n<\/div>\n

\n
\"Right<\/a>

Right Eye<\/p><\/div>\n<\/div>\n<\/div>\n

\n
\n
\n

Answer and Learning Points<\/h3>
\n

Answer<\/strong><\/p>\n

The ultrasound clips demonstrate hypoechoic material in the orbits bilaterally, swirling around with subtle eye movement. This is consistent with bilateral vitreous hemorrhage.\u00a0The diagnosis was discussed with the patient and he was referred to ophthalmology clinic for dilated eye exam in 24 hours.<\/p>\n

Learning Points<\/strong><\/p>\n

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.\u00a0Since it is difficult to obtain\u00a0 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.\u00a0 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:<\/p>\n

\"\"<\/p>\n

    \n
  1. \n
      \n
    1. Prepare the patient by laying the bed backwards and having their face parallel to the ceiling,\u00a0 supporting the patient's head and neck with a pillow or blanket.<\/li>\n
    2. Place a tegaderm over the eye (optional). If you do, ensure there is no air between the tegaderm and the eyelid.<\/li>\n
    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.<\/li>\n
    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.<\/li>\n
    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.<\/li>\n
    6. Repeat this technique with the probe marker pointed superiorly and have the patient again look in all directions.<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

      \"\"<\/p>\n

      Retinal detachment:<\/strong> The common POCUS findings include a thin linear structure tethered to the optic nerve.\u00a0 It flaps back and forth as the eye is moved giving it the appearance of \u201cswaying seaweed\u201d. This is an ophthalmologic emergency, especially if the macula is still attached,\u00a0 the ophthalmologist should be immediately consulted.<\/p>\n

      \"\"<\/p>\n

      Vitreous hemorrhage: <\/strong>You will notice a diffuse mobile opacity often described as a \u201csnow globe\u201d 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.<\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n

      \n
      \n
      \n

      Author<\/h3>
      \n

      This post was written by Sam Frenkel, MD, PGY-2 UCSD EM. It was reviewed by Michael\u00a0Macias, MD, Ultrasound Fellow at UCSD.<\/p>\n<\/div><\/div>\n

      References<\/h3>
      \n
        \n
      1. \n
          \n
        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.<\/li>\n
        2. Dawson, Mallin.\u00a0Introduction to Bedside Ultrasound, Volume 2.<\/i>\u00a02013. Apple iBook.<\/li>\n
        3. Kilker B, Holst J, Hoffmann B. Bedside ocular ultrasound in the emergency department.\u00a0<\/span>Eur J Emerg Med<\/i>. 2014;21(4):246-253.<\/span><\/li>\n
        4. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment.\u00a0<\/span>J Emerg Med<\/i>. 2011;40(1):53-57.<\/span>\u00a0<\/span><\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"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\u00a0moving 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 …

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