The Case:
A 66yo male with PMH of coronary artery disease, type II diabetes, hypertension and hyperlipidemia presented with acute onset blurry vision in his left eye that began shortly before arrival. The patient described “squiggly lines” in the left visual fields of his left eye. He denied any pain or other symptoms. No recent history of trauma.
On exam patient had no neuro deficits and visual acuity was 20/50 bilaterally. The patient had decreased peripheral vision in the outer upper quadrant of the left eye but otherwise PERRL, EOMI and his intraocular pressures were normal. No signs of infection.
Differential Diagnosis:
- CVA
- Retinal detachment
- Vitreous detachment/hemorrhage
- Central retinal artery occlusion
- Central retinal vein occlusion
- Lens dislocation
- Optic neuritis
- Optic nerve ischemia
- Temporal arteritis
The Ultrasound:
The POCUS shows a posterior vitreous hemorrhage without signs of retinal detachment.
Disposition:
The patient followed up in ophthalmology clinic the next day and posterior vitreous detachment and hemorrhage was confirmed without a retinal detachment. The patient was discharged with precautions and instructions to follow up in 4 to 6 weeks.
Discussion/Teaching Points:
Presentation:
Patients typically present with painless blurry vision and often describe floaters or flashes.
Etiology:
Causes of vitreous hemorrhage include posterior vitreous detachment, retinal detachment, trauma, various vasculopathies and retinopathies, blood dyscrasias, neovascular age-related macular degeneration or (rarely) in the setting of intracranial hemorrhage.
Incidence has been described as rare as 7 cases per 100,000 or as frequent as 4.8 cases per 10,000.
Risk factors include older age, diabetes, other causes of retinopathy or vasculopathy, male gender and use of anticoagulants.
Diagnosis:
Several advanced retinal or funduscopic imaging techniques may be used but the primary imaging modality is ultrasound.
Ultrasound:
To perform an ocular ultrasound, a barrier/tegaderm can be placed over the patient’s eye for protection and sufficient gel should be placed over the eye so the probe can make full contact without any air pockets. The linear/high resolution probe (7.5 to 10 MHz) is used and a transverse and longitudinal sweep through the eye should be performed. It is also important to have the patient move their eyes from side to side under ultrasound as this will often make echogenic material (such as vitreous hemorrhage) more visible.
In a normal eye under ultrasound, the lens and often the iris/pupil should be visible anteriorly and the posterior chamber should be anechoic. Posteriorly the optic nerve sheath should be visible behind the retina.
In the case of a vitreous hemorrhage, POCUS will show echogenic material in the posterior chamber that is mobile but not tethered at the optic nerve (as with a retinal detachment). A posterior vitreous detachment may also be seen and is important to distinguish from a retinal detachment.
Overall, POCUS has been shown to be very accurate for evaluation of ocular pathology in the emergency department. Ocular ultrasound has been shown to have a sensitivity of 82% and a specificity of 82% for vitreous hemorrhage. Additionally, it has been shown to have a sensitivity of 97% and a specificity of 88% for retinal detachment.
Treatment:
In the absence of a retinal detachment, a simple vitreous hemorrhage can be managed conservatively without invasive intervention. Patients should have ophthalmology follow-up within 48hrs and are often monitored in the outpatient setting for improvement. In cases of retinal detachment, emergent ophthalmology consultation is required in the ED.
Complications:
Complications are rare and are mostly related to the blood and breakdown of blood in the posterior chamber. Complications can include glaucoma and hemosiderosis which can lead to peripheral vision loss, night blindness, loss of macular function and xanthopsia.
References:
Blaivas, M., Theodoro, D. and Sierzenski, P.R. (2002), A Study of Bedside Ocular Ultrasonography in the Emergency Department. Academic Emergency Medicine, 9: 791-799.
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.
Lindgren G, Sjödell L, Lindblom B. A prospective study of dense spontaneous vitreous hemorrhage. Am J Ophthalmol. 1995 Apr;119(4):458-65.
Wang CY, Cheang WM, Hwang DK, Lin CH. Vitreous haemorrhage: a population-based study of the incidence and risk factors in Taiwan. Int J Ophthalmol. 2017;10(3):461-466.
Jena S, Tripathy K. Vitreous Hemorrhage. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.