Liz Volochyna-Farber
A 37-year-old male with a past medical history of retinal detachment (RD) of the left eye (OS), left eye cataract surgery and retinal tear in the rigth eye (OD) s/p laser presents to Emergency Department (ED) on a Sunday with painless worsening right eye vision. It started with a floater in the eye 2 days prior. The patient went to an outside ED, has been given a diagnosis and was told to see ophthalmology, but was unable to do that over the weekend. Meanwhile his symptoms worsened, so he came to our ED. He endorsed mild itching to the eye but denied trauma, pain, foreign body sensation, fever and neurologic changes.
Eye exam: PERRL, EOMI, no injection/discharge, no nystagmus, no corneal abrasion or fluorescein uptake b/l, left superior field defect present OD, visual acuity OD 20/400 pinhole corrected to 20/40, OS 20/20-2, IOP L13, R13
An ocular ultrasound is performed and the images below are seen. What do you see, and what is his most likely diagnosis? What is your management?
Figure 1: Right eye.
Figure 2: Right eye kinetic scan. Retinal detachment (arrows) is demonstrated by a bright, echogenic membrane tethered to the optic disc (star) in image B. The optic nerve and disk can be seen in the lower right corner of image A, while in image B, the disk is positioned more medially, with tethering observed, though the retina is detached to the left of the optic disc.
Ophthalmology was consulted at the bedside. On a dilated fundoscopic exam of the right eye, a mac-off retinal detachment (RD) was noted temporally between 6:00 and 10:30, extending onto the temporal macula next to the fovea, with a hole at the 8:00 position, likely the causative break. Surgery was recommended within the next few days. Records from an outside emergency department were not obtained, but it is possible that the patient initially presented with a mac-on RD, and if treated immediately, could have had a better prognosis.
Learning points
- Retinal detachment is a serious ocular condition that can lead to permanent vision loss and can be directly visualized using point-of-care ultrasound (POCUS) and diagnosed with sensitivity of 96.9% and specificity of 88.1%. [1]
- In a normal eye, the vitreous cavity appears as a circular hypoechoic structure, with the hyperechoic retina indistinguishable from the underlying hyperechoic choroid. In retinal detachment, the neurosensory retina separates from the choroid and appears on ultrasound as a distinct hyperechoic line still tethered to the optic disc.
- Proper ultrasound technique involves placing a high-frequency linear transducer over a gel-covered closed eyelid. Both static and kinetic images should be obtained, with scanning done in transverse and longitudinal planes. In the static exam, the patient holds the eye still while the examiner fans through the orbit. In the kinetic exam, the examiner holds the probe steady while the patient moves the eye left and right.
- It's crucial to determine whether the macula is attached (mac-on) or detached (mac-off) as this affects treatment urgency. The macula, located lateral to the optic nerve, is vital for central, high-acuity vision. In mac-on detachment, where only the peripheral retina is detached, urgent treatment ideally within 24 hrs is required to prevent central vision loss.[2,3] In mac-off detachment, visual prognosis is worse, but treatment within 7 to 10 days shows no difference in outcomes compared to treatment within 24 hours.[1] While there are no large-scale studies on utilizing POCUS to differentiate between mac-on vs. mac-off RD, diagnosing RD alone should prompt an urgent ophthalmology evaluation that will expedite the urgent surgery when needed. Progression from mac-on to mac-off can occur in hours to days, depending on factors such as pseudophakia, retinal break location, vitreous liquefaction, and age.[3,4]
References:
- Lahham, S., Shniter, I., Thompson, M., Le, D., Chadha, T., Mailhot, T., Kang, T. L., Chiem, A., Tseeng, S., & Fox, J. C. (2019). Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA network open, 2(4), e192162. https://doi.org/10.1001/jamanetworkopen.2019.2162
- Blair K, Czyz CN. Retinal Detachment. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551502/
- Wiedemann P. (2024). When to repair a retinal detachment?. International journal of ophthalmology, 17(4), 607–609. https://doi.org/10.18240/ijo.2024.04.01
- Mundae, R., Velez, A., Sodhi, G. S., Belin, P. J., Kohler, J. M., Ryan, E. H., & Tang, P. H. (2022). Trends in the Clinical Presentation of Primary Rhegmatogenous Retinal Detachments During the First Year of the COVID-19 Pandemic. American journal of ophthalmology, 237, 49–57. https://doi.org/10.1016/j.ajo.2021.11.017