Case vignette
62yo F w/ DM p/w L eye pain after falling and hitting her face.
BP 120/80, HR 80, RR 16, SpO2 98%, T 37. VA reduced on OS.
L periorbital ecchymosis. Reduced pupillary response to light. EOMs are intact but painful. Seidel's negative on fluorescin. Left IOP ~25 on tonometry. Remainder of primary/secondary exams reassuring.
What do you see?
Oc2 US1: hyperechoic irregularities in anterior chamber and echogenic material in posterior chamber
Oc2 US2: heterogeneous, hyperechoic debris in posterior chamber, concerning for blood. "Washing machine sign" with kinetic exam (eye movement left and right)
Oc2 US3: again, washing machine sign. No evidence of retinal detachment
Oc2 US4: lens appears displaced. Iris disrupted and frayed
Oc2 US5: lens appears anteriorly dislocated, abutting cornea. Note focus (green arrow on right) has been changed to 1cm
Oc2 picture: optic nerve sheath diameter is within normal limits. Even though IOP (intraocular pressure) is elevated on exam, this US suggests intracranial pressure (ICP) is not
What do you do next?
Whew. A lot is wrong with this eye. You suspect both vitreous hemorrhage and lens detachment and consult Ophtho. You don’t see retinal detachment but know vitreous hemorrhage can be accompanied by vitreous detachment. Based on the IOP, you think a retrobulbar hematoma is less likely, or at minimum no emergent lateral canthotomy is indicated.
You obtain a hCT and CT max face to rule out additional injuries, and scans are negative.
Ophtho recommends admission to medicine with serial examinations, anticipating potential OR in the next day.
Teaching points. POCUS can assist with multiple time sensitive ocular diagnoses. Using lots of gel, instruct the patient to keep their eyes closed and "float" a linear probe over the orbit. You can also place a Tegadarm over the eye. Visualize the anterior and posterior chambers. Have the patient look left and right. You can also assess optic nerve sheath diameter.
Vitreous hemorrhage is represented by echogenic/heterogeneous material in the posterior chamber, representing blood. It looks like debris. When the patient moves their eye (a kinetic exam), the blood moves then settles. This causes what is often described as a washing machine sign. Note vitreous hemorrhage can be accompanied by retinal or vitreous detachment.
For further discussion, please see these excellent posts:
Vitreous hemorrhage: https://turbot-hypersphere-w8wz.squarespace.com/config/pages/606b7a8cde99506c856b627c
Lens dislocation: https://www.tamingthesru.com/blog/annals-of-b-pod/quick-hit/traumatic-lens-dislocation
Elevated intracranial pressure: https://emcrit.org/pulmcrit/pulmcrit-algorithm-diagnosing-icp-elevation-ocular-sonography/
Residents/staff: Dr. Julia Palmer, Dr. Daniel Hubbard
Vitreous Hemorrhage + Lens Detachment
March 2018