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The Case Files: Ultrasound Diagnoses Ocular Complaint

Lombardi, Joel, MD; Guy, Allysia, MD

doi: 10.1097/01.EEM.0000530200.28139.60
The Case Files

Dr. Lombardiis a second-year resident in emergency medicine, andDr. Guyis the director of emergency ultrasonography, both at Lincoln Medical and Mental Health Center in Bronx, NY.

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A 41-year-old man with a medical history of diabetes mellitus presented to the ED with the chief compliant of not being able to see out of his left eye. The patient said he woke up two days earlier with painless vision loss of his left eye. He believed that he may have rubbed or scratched his eye, and he expected that his symptoms would eventually go away.

He had been using an unknown over-the-counter topical medication without relief. The day of presentation, he awoke with a left-sided headache described as gradual in onset with moderate severity. The patient denied history of trauma to the eye, previous similar symptoms, floaters, recent illness, headaches, dizziness, nausea, vomiting, fever, chills or weight loss.

Medication reconciliation was significant for Humalog and glargine insulin. He had no history of allergies, and denied using tobacco, alcohol, or recreational drugs. Family history was not disclosed.

His vital signs were temperature of 98.0°F, pulse of 87 bpm minute, blood pressure of 131/82 mm Hg, respiration rate of 18 bpm, and oxygen saturation of 99% on room air. Fingerstick glucose was 274 mg/dL. His neurological exam was significant for left cranial nerve II decreased visual acuity in central vision, no peripheral or nasal vision loss, cranial nerves III-XII intact without motor or sensory deficit, normal gait, no ataxia, fluent speech/comprehension, no dysarthria, 5/5 upper and lower extremity strength, and intact sensation. Head exam was normocephalic and atraumatic.

His oropharnyx was normal in appearance without lesions, his mucous membranes were moist, and his neck was supple. Extraocular muscles were intact with no nystagmus. Pupils were equal, round, and reactive to light. The left eye had infected conjunctiva.

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Cloudy and Pale

Funduscopic examination showed his right eye with 3:1 cup:disc ratio and no hemorrhage. The left eye visual exam was limited, but it appeared cloudy and pale. Visual acuity was 20/20 for the right eye, but the patient was unable to read the Snellen chart with his left eye. Fluorescein examination was negative. His left eye had trace hypopyon. Left eye pressure was 6 mm Hg; right-sided eye pressure was not documented.

Heart sounds S1 and S2 were auscultated with regular rate and rhythm without murmurs. Pulmonary exam was clear to auscultation bilaterally with no wheezes, rales, or rhonchi appreciated. The abdomen was soft, not tender, and not distended. The patient's skin was warm and dry without rashes or cyanosis.

Brain CT showed no acute focal intracranial pathology. Bedside ocular ultrasound by emergency physicians revealed abnormal hyperechoic material in the posterior aspect of the vitreous body. (See figures.) The exam did not reveal findings consistent with retinal detachment, lens dislocation, or vitreous hemorrhage.

The patient received urgent ophthalmology consultation at our institution based on history and the results of abnormal ED bedside ultrasonography examination. He was determined to have panuveitis suspicious for toxoplasmosis. The patient was discharged with sulfamethoxazole/trimethoprim, clindamycin, and prednisolone acetate ophthalmic suspension, and was instructed to follow up with the ophthalmology clinic in two days.

The patient followed up six days later, and laboratory testing for syphilis, anti-nuclear antibodies, rheumatoid factor, angiotensin-1-converting enzyme, and QuantiFERON tuberculosis were drawn. The antinuclear antibody titer was 1:80 (normal titer <1:80), and the rest of these studies were unremarkable. The patient declined further follow-up after four weeks.

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POC Ultrasound

Ocular emergencies diagnosed in the ED require detailed physical examination and knowledge of potentially critical diagnoses. The physical exam can be complicated by altered mental status, injury, edema, corneal abrasions, hyphema, hypopyon, and cataracts. The superficial location of the eye and its aqueous composition enables quick bedside ultrasonographic assessment that can differentiate between normal and pathological disease states.

The use of ultrasound to accelerate the diagnosis of ocular emergencies has been documented in the literature in cases that include examples of retinal detachment, retrobulbar hematoma, globe penetration, lens dislocation, vitreous hemorrhage, retinal vein and artery occlusion, and foreign body retention. (Acad Emerg Med 2000;7[8]:947 and 2002;9[8]:791.) This case report demonstrates using point-of-care ultrasound in diagnosing an additional pathological condition that presents regularly in the ED and requires prompt intervention for optimal outcome.

Bedside ultrasonography in the ED has been used more frequently to diagnose and treat acute conditions. Prompt suspicion of uveitis in the ED, and communication with ocular specialists can improve quality of patient care. Approximately 10 percent of visual disability in the United States can be attributed to uveitis, which accounts for about 30,000 new cases of blindness each year. (Int Ophthalmol 1990;14[5-6]:303.) ED point-of-care ultrasound findings of panuveitis have not been documented in the literature previously, to our knowledge.

Ultrasonography may be especially useful at diagnosing intraocular inflammatory conditions when visualization of the fundus is poor due to media haze. (Saudi J Ophthalmol 2014;28[2]:95.) It can also be used to examine the ciliary body and pars plana, which are often involved in uveitis and can be difficult to visualize on routine visual exam. (Eye [Lond] 2001;15[Pt 1]:23.)

Ultrasound biomicroscopy to manage uveitis has shown clinical value and improved patient management. (Eye [Lond] 2001;15[Pt 1]:23.) Ultrasound biomicroscopy (high-frequency ultrasound) is the diagnostic imaging of choice for uveitis by ophthalmologists because the structures involved are not easily accessible with conventional visual examination techniques. (Br J Ophthalmol 1998;82[6]:625.) EDs are typically not equipped with biomicroscopy, though our ED ultrasound is equipped with a 25 Hz high-frequency linear probe, while typical ultrasound biomicroscopy involves using higher frequency probes (35-50 MHz). (Clin Exp Ophthalmol 2009;37[1]:54.)

Our examination technique is typically facing the probe marker toward the patient's right side, but evaluation with the probe marker positioned cephalad enables evaluation of the entire posterior eyeball from super to inferior edge. In our opinion and experience, fanning at both positions through multiple planes increases sensitivity of detecting ocular abnormalities. The ability to detect panuveitis in the ED via point-of-care ultrasound technique has great potential to improve clinical management.

Ocular emergencies account for three percent of ED visits. (Br J Ophthalmol 1998;82[6]:625.) Recognizing, understanding, and determining management are critical skills for emergency physicians. Incorporating bedside ocular ultrasound into routine physical examination facilitates more accurate diagnosis and management strategies.

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