Martin Day, Elaine Yu
A 69-year-old male with no significant past medical history presented to the emergency department after striking his right eye with the handle of a spray hose at work. He reported burning pain but denied bleeding, tearing, or other injuries. Eye movement did not exacerbate the pain. Notably, he had been chronically blind in the right eye since childhood after sustaining blunt ocular trauma from being kicked by a cow around age 12. He described no perception of light in that eye since then.
Vitals: BP 138/83 | Pulse 85 | Temp 98.4F (36.9C) | Resp 17 | SpO2 98%
Physical Exam:
On physical examination, the patient was alert and cooperative, not in acute distress. The right eye did not demonstrate periorbital ecchymosis or signs of obvious trauma. There was negative fluorescein uptake, extraocular movements intact, and pupil fixed. He had no light perception. His left eye was normal on examination.
A bedside ocular ultrasound was performed:
Figure 1. Bi-convex lens with hyperechoic but irregular borders.
Figure 2. Ocular ultrasound depicting hyperechoic debris within the posterior chamber and vitreous hemorrhage, represented as materials of varying echogenicity within the vitreous body.
ED Course
Pain was treated conservatively with topical anesthetics and fluorescein for exam. Patient did not require any acute intervention. He was reassured, educated on return precautions, and discharged in stable condition.
Discussion
Blunt ocular trauma can cause profound and often irreversible injury. In this patient, a cow kick to the eye at age 12 resulted in permanent blindness. Decades later, a new minor injury prompted re-evaluation, but his underlying chronic pathology was the dominant finding.
Despite an apparently benign surface exam—negative fluorescein, intact EOMI, no external trauma—ultrasound revealed chronic posterior segment pathology: vitreous detachment, hemorrhage, and irregular lens, consistent with his long-standing blindness. Notably, POCUS excluded emergent findings such as global rupture or retinal detachment.
The American College of Emergency Physicians recommends POCUS for assessing the posterior segment of the eye. Multicenter trials and meta-analyses convey high sensitivity and specificity for retinal detachment (96.9% sensitivity, 88.1% specificity), moderate diagnostic accuracy for vitreous hemorrhage (81.6% sensitivity, 82.3% specificity), and lower sensitivity (42.5%) but high specificity (96.0%) for vitreous detachment [1,2,3,5]. Additionally, POCUS was 100% sensitive and 97% specific for lens dislocation, and 100% sensitive and 99% specific for intraocular foreign body according to another meta-analysis [1,5].
Vitreous hemorrhage appears on ocular ultrasound as a fluid collection of variable echogenicity within the posterior chamber of the globe. The hemorrhagic material typically is mobile, shifting as the patient moves their eye while the probe remains still [2]. In chronic cases, fibrotic changes may cause the echogenic fluid collection to appear denser and more organized [1,2]. Vitreous detachment appears as a mobile, hyperechoic membrane in the posterior chamber, like vitreous hemorrhage, during kinetic examination [3]. Retinal detachment can be differentiated from vitreous detachment because it appears more echoic and anchored to the optic disc, which was not appreciated in this case [2,3]. The lens on ocular ultrasound may appear irregular in its position or contour [3]. This patient’s lens appeared typically centered behind the iris without evidence of dislocation. However, the margins were poorly defined, with irregular, asymmetric borders, suggestive of a lens irregularity [3,6].
In emergency medicine, ocular ultrasound offers a quick and effective means of evaluating both acute injuries and chronic sequelae. This case highlights the value of ultrasound in diagnosing both acute and chronic ocular pathology. It allows rapid, non-invasive assessment of posterior structures even when vision is absent or the anterior exam appears normal. A visit to the ED for a minor workplace incident uncovered sequela of a childhood injury. Additionally, clinical judgment helped guide diagnosis. With no suspicion of intraocular foreign body or orbital fracture, CT was deemed unnecessary. Ultrasound was sufficient to distinguish chronic from acute findings. POCUS may be especially useful for assessing unreliable historians. POCUS does not replace the comprehensive ophthalmologic evaluation [4]. Nonetheless, it serves as a crucial tool for rapid bedside assessment for urgent intervention [4].
References
- American College of Emergency Physicians. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Irving, TX: American College of Emergency Physicians; 2023.
- 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 Netw Open. 2019;2(4):e192162. doi:10.1001/jamanetworkopen.2019.2162
- Pyle M, Gallerani C, Weston C, Frasure SE, Pourmand A. Point of care ultrasound and ocular injuries: a case of lens dislocation and a comprehensive review of the literature. J Clin Ultrasound. 2021;49(3):282-285. doi:10.1002/jcu.22904
- Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799. doi:10.1111/j.1553-2712.2002.tb02166.x
- Propst SL, Kirschner JM, Strachan CC, et al. Ocular point-of-care ultrasonography to diagnose posterior chamber abnormalities: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(2):e1921460. doi:10.1001/jamanetworkopen.2019.21460
- Özdal M, Mansour M, Deschênes J. Ultrasound biomicroscopic evaluation of the traumatized eyes. Eye (Lond). 2003;17(4):467-472. doi:10.1038/sj.eye.6700382
