A 35-year-old man presents to the ED with a complaint of blurred vision. He said he was hit in the face three days earlier, and he describes decreased vision to his right eye with the ability to distinguish only shapes and colors.
He also complains of pain to the eye and sensitivity to light. The affected conjunctiva appears injected, and the pupil is reactive to light but appears to be misshapen. His visual acuity is markedly decreased to the affected eye, and he has significant photophobia and cannot tolerate a funduscopic exam. Ultrasounds of his eye reveal the diagnosis: a lens dislocation, another diagnosis that can be readily made at the bedside.
The image on the left demonstrates a normal eye. The morphology of the globe is recognizable and easily identified. The anterior chamber can be seen at the top of the image, as the crescent-shaped area. The lens can be seen as the hyperechoic (white) round object sitting between the anterior and posterior chamber. The pupil is the less hyperechoic (gray) area to the right and left of the lens. The image to the right shows a lens dislocation. The globe again can be easily identified. The anterior chamber is seen at the top of the image, but the lens is not in its expected location. It is seen instead at the posterior aspect of the posterior chamber.
An ocular ultrasound is performed with a high-frequency transducer to maximize the resolution necessary to identify the eye and its structures. A “pillow” of ultrasound gel should be applied first to the patient's closed eye. The transducer can then be lightly applied to the gel, providing an ideal window for visualizing the eye. Brace the scanning hand on the patient's forehead, resting the heel of the hand on the patient's forehead or cheek, and use the gel “pillow” to minimize the amount of pressure applied to the eye. Minimizing the amount of pressure on the orbit is especially important in cases of trauma when an open globe cannot be ruled out.
Ultrasound of the eye is a valuable skill for the emergency physician. Many clinicians feel uncertain when evaluating patients with complaints of eye pain or visual disturbances. Evaluating the fundus may prove daunting or difficult in the emergency department when the ideal equipment and environment may not be available, but ultrasound is a rapid modality for evaluating the eye for a number of findings, including lens dislocation, retinal detachment, foreign body, open globe, and central retinal artery occlusion.
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An editing error in Dr. Butts' last column caused the captions to be placed under the wrong photos. A correct version of the article is available on our website at http://bit.ly/UltrasoundHipPain. EMN apologizes for the error.