This patient has large cataracts bilaterally and a vitreous hemorrhage in the right eye, confirmed by head CT. She received compazine, benadryl and her home BP meds and her headache resolved without further treatment and she was discharged home. The headache was likely secondary to her untreated HTN.
Ocular Ultrasound
Ultrasound has been used to evaluate the eye since the late 1960s, but has only been adopted for ED use for the past decade. It is an easy non-invasive way to evaluate the eye in patients who present with: vision loss, eye pain, suspected foreign body, ocular trauma, or closed head injury.
Using a high frequency probe (preferable linear, but could use an endocavitary probe if that's all you have), have the patient close their eye and fill their eye socket with ultrasound gel. Place the probe gently on the orbit over the closed lid in the transverse plane. Brace your hand by creating a "kickstand" with your pinky finger, and fan through the eye top to bottom. Make sure that you identify all anatomy and note any abnormalities.
In this case specifically, there is an abnormality of the lens. Normally only the posterior portion of the lens is visible, but with cataracts, the entire lens become apparent as a hyperechoic region. This case also presents an interesting finding in the vitreous humor. There appears to be a hyperechoic area, but is it a retinal detachment or a vitreous hemorrhage? Vitreous hemorrhage appears as echogenic material in the posterior chamber. Depending on the age and severity, a vitreous hemorrhage may have a varied appearance on ultrasound. Small dots or linear areas may be fresh mild hemorrhages but more severe and older bleeds can organize and forms membranes. Gravity may layer out vitreous bleeds inferiorly. Retinal detachment could be mistaken for a older layered out vitreous hemorrhage to the untrained eye. However, note that usually retinal detachments appear as a hyperechoic wavy line in the posterior to lateral globe, not as a linear or straight line.
On another note, there is a cool trick in evaluating pupillary constriction with ultrasound in patients with significant ocular/facial trauma where you are unable to open the eye. Ultrasound can be used to visualize the pupil if there is so much edema to the orbit that the lid cannot be retracted. This is performed by placing the ultrasound probe on the edematous affected eye while a light is shined on the contralateral pupil and the pupil in the affected eye is monitored. The pupil will retract and an opening within is visualized.
Thanks to Michelle Lin for this awesome ultrasound trick! Thanks to ED Tech and Future Ultrasonographer Todd for being the model for this post!