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Emergency Ultrasound

Cases That Count: I Spy a Swollen Eye

By Kevin Carey, MD & Marsia Vermeulen, DO, FACEP
NYU Medical Center/Bellevue Hospital Center
New York, NY

Chief Complaint: Eye trauma

Image 1

SwollenEye1

Clip 1 - Ocular Ultrasound

Questions:

  1. Identify the structures in Image 1 and Clip 1. What are the important landmarks to identify?
  2. What are your differential diagnoses and how do you differentiate between them?
  3. What are the potential complications of this clinical entity?
  4. In what other ways can point-of-care bedside ultrasound (POCUS) be helpful in the setting of ocular trauma?


Case Presentation

A 28-year-old healthy male presented to the ED at 3am with chief complaint: “I got sucker-punched and now I can’t see out of my left eye.” He denied LOC or other associated injuries. Following the assault the patient reported decreased vision out of his left eye “like looking through cobwebs,” and seeing occasional flashes of light. He denied acute pain with extra-ocular movements (EOM), headache, nausea, vomiting, or rhinorrhea.

He was sitting comfortably on a hospital stretcher, answering questions appropriately. His vital signs were: heart rate 95, blood pressure 135/88, respiratory rate 16, O2 saturation 100% on room air. His facial exam was significant for marked left eyelid edema with periorbital erythema, as well as left sided tenderness to palpation over the zygomatic arch without crepitus or deformity. There was no post-auricular ecchymosis, hemotympanum, nasal instability, septal hematoma or signs of rhinorrhea. With eyelid opening, his sclera on the left was mildly injected without hyphema, his pupils were equal and reactive to light bilaterally and EOM appeared to be intact and full. He could count fingers with the affected eye and his intraocular pressure via tonopen was 17mmHg. There were no other signs of trauma on exam. After the initial evaluation, a head and facial CT were ordered and an ocular POCUS was performed.

Role of Point-of-care Ocular Ultrasound in the Emergency Department

Ophthalmologic complaints comprise approximately 2-3% of all ED visits.1 Acute changes in a patient’s vision can be a frightening experience and the differential includes time-sensitive pathology that has the potential for long-term disability.

A traditional comprehensive ophthalmologic exam can be challenging in the ED setting where specialized equipment and expertise are not always present. Furthermore, soft tissue swelling from facial trauma can impede an exam altogether. POCUS can be used to evaluate the globe and surrounding tissues in a safe, rapid and non-invasive manner.2
Our POCUS demonstrated a retinal detachment. The facial CT revealed a zygomatic arch fracture. Preoperative labs were added and the patient was admitted to the facial trauma service where he was observed and his retinal detachment was repaired by the ophthalmology service.

Answers to Questions:

  1. The lens is in the appropriate location. The retinal detachment is the well-defined hyperechoic structure anchored to the optic disc (see Image 2, below).
  2. The differential diagnosis for traumatic vision loss includes: corneal abrasion, foreign body, hyphema, traumatic iritis, lens dislocation, retinal detachment, vitreous hemorrhage, traumatic optic neuropathy, acute maculopathy and globe rupture. With his history and exam, we were concerned about possible retinal detachment or vitreous hemorrhage.
  3. Classically, retinal detachment presents as a sudden, painless, monocular visual disturbance. Patients describe a sensation of looking through a curtain, accompanied by flashes and floaters. Ocular POCUS used to diagnose retinal detachment has a sensitivity ranging from 97–100% with a specificity of 83–100%.3 On ultrasound a retinal detachment appears as a sharply defined, highly reflective linear membrane that is anchored to the optic disc. The retina may be accentuated and wave with eye movements due to this anchoring. Vitreous detachment is often mistaken for a retinal detachment. Unlike a retinal detachment, a vitreous detachment is more delicate and thin, less echogenic, and does not attach to the optic disc. Such differences can be exaggerated with eye movements, which has been shown to raise the specificity to approximately 92%.4
  4. A retinal detachment occurs when the neurosensory retina and the underlying choroidal circulation separate, resulting in ischemia and rapid, progressive photoreceptor degeneration. It is more commonly spontaneous but can also be seen in the setting of trauma. If not addressed within 24 hours, the underlying ischemic damages can become irreversible, resulting in permanent vision loss.5
  5. Ocular POCUS can be used in the trauma setting to assess pupillary function, EOM function, lens dislocation, increased intracranial pressure, and even globe rupture. The lens should be observed during EOM in order to accentuate abnormalities and should always be compared to the contralateral side. In patients with severe periorbital edema and concern for extraocular muscle entrapment, the pupillary reflex can be examined with ultrasound.6 For skilled ultrasonographers, one study demonstrated that an optic nerve sheath diameter of > 5mm on POCUS is 95.6% sensitive and 92.3% specific for elevated intracranial pressure when compared to CT.7 Extra caution needs to be exercised when evaluating the patient for globe rupture, as inadvertent pressure can cause vitreous extrusion.8  

Image 2

SwollenEye2

References

  1. Carmody K, Moore C, Feller-Kopman D. Ocular Ultrasound in Handbook of Critical Care & Emergency Ultrasound. New York, NY: McGraw Hill, 2011, p.185.
  2. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002; 9(8):791–799.
  3. Vrablik ME, Snead GR, Minnigan HJ, et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Acad Emerg Med. 2015; 65(2): 199–203.
  4. Shinar Z, Chan L, Orlinsky M. Use of Ocular Ultrasound for the Evaluation of Retinal Detachment. J Emerg Med. 2011; 40(1): 53-7.
  5. Bowling B. Retinal detachment. In: Bowling B, ed. Kanski's Clinical Ophthalmology. 8th ed. Philadelphia, PA: Elsevier Saunders; 2016: Chapter 16.
  6. Harries A, Shah S, Teismann N, et al. Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma. Acad Emerg Med. 2010; 28(8): 956-9.
  7. Ohle R, McIsaac SM, Woo MY, et al. Sonography of optic nerve sheath diameter for detection of raised intracranial pressure compared to computed tomography: a systematic review and meta-analysis. J Ultrasound Med. 2015; 34(7): 1285-94.
  8. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002; 9: 791-799.



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