“What’s in My Eye” - Identification of Vitreous Hemorrhage with Ocular Ultrasound

case

This patient is a 57 year old female who had no known medical history who presented to the emergency department for visual disturbances. She noted that before the day of presentation, she was in her regular state of health and had no complaints prior to that day. However, on the day of presentation, she woke up with “dark flashes” and multiple floaters in her left eye. She stated that she thought something got into her eye. She did not have any headaches, numbness, tingling, weakness, eye pain, or changes in speech. She had not seen a provider in many years. 

Her vitals were notable for an initial blood pressure of 246/142 and a pulse of 110 but otherwise, the rest of her vitals were stable. Her physical exam was only notable for loss of the lateral visual field in her left eye, but she had no other visual losses, eye abnormalities, or neurological changes. 

Her work-up was notable for an initial blood glucose of 433 mg/dL. The patient was activated as a Code Stroke. Her CT imaging was negative and in discussions with the neurology team, thrombolytics were not given. At that time, she had a bedside ocular ultrasound done which showed the following:

Image 1: Ocular ultrasound of the left eye showing hyperechoic region in the vitreous chamber, concerning for vitreous hemorrhage

diagnosis

Ophthalmology saw the patient and confirmed mixed diabetic and hypertensive retinopathy OU (in both eyes) with vitreous hemorrhage OS (left eye).

discussion

Vitreous hemorrhage is a common cause of sudden onset vision changes. This happens when there is bleeding into the most posterior chamber, the vitreous chamber, of the eye. This commonly happens due to breakage of the friable vessels in the eye. These vessels are prone to neovascularization and can spontaneously rupture. The most common cause of vitreous hemorrhage is proliferative diabetic retinopathy, from undiscovered or poorly controlled diabetes mellitus. Other causes of vitreous hemorrhages are posterior vitreous detachment, trauma, central retinal vein occlusion,  sickle cell retinopathy, and radiation retinopathy. [1]

While there are many modalities that can be used to visualize vitreous hemorrhage, the fastest option in the emergency department is an ocular ultrasound. It can help find vitreous hemorrhages, retinal detachments, and can be used to measure optic sheath diameter to assess for papilledema. Ocular ultrasound has a 94% sensitivity and 96% specificity for retinal detachment. For vitreous hemorrhage, ocular ultrasound has a 100% sensitivity and 92% specificity. [2,3,4]

When performing an ocular ultrasound, it is important to know the difference between vitreous hemorrhage (which may have associated detachment) and retinal detachment. Vitreous hemorrhage will appear as echogenic debris in the globe that is free-floating, moves when the patient moves their eye (often called the “washing machine sign”), and does not have disruption at the optic disk. Retinal detachment appears as a hyperechoic line which is typically attached to the optic nerve posteriorly.  It can appear like a “V” shape where it is tethered down. [5,6]

case resolution

She was admitted to the internal medicine service with ophthalmology following and received appropriate blood pressure and diabetes treatment. The vitreous hemorrhage self-resolved, and her vision returned to normal.

take-aways

  • Vitreous hemorrhage is a common cause of sudden onset painless vision changes

  • Vitreous hemorrhage is commonly caused by proliferative diabetic retinopathy or trauma

  • Ultrasound has a very high sensitivity and specificity for locating retinal detachments and vitreous hemorrhages

AUTHOR: Dr. Christian Keenan, MD is a second-year emergency medicine resident at Brown Emergency Medicine Residency.

FACULTY REVIEWERS: Dr. Kristin Dwyer, MD is an Associate Professor of Emergency medicine and the Director of the Division of Emergency Ultrasound at Brown Emergency Medicine. Dr. Leland Perice is an Assistant Professor of Emergency Medicine and Ultrasound Faculty at Brown Emergency Medicine.

references

  1. Shaikh, Nawazish; Srishti, Ramamurthy1; Khanum, Aayesha2; MB, Thirumalesh2; Dave, Vivek1; Arora, Atul3; Bansal, Reema; Surve, Abhidnya; Azad, Shoryavardhan; Kumar, Vinod. Vitreous hemorrhage – Causes, diagnosis, and management. Indian Journal of Ophthalmology 71(1):p 28-38, January 2023. | DOI: 10.4103/ijo.IJO_928_22

  2. Rabinowitz R, Yagev R, Shoham A, Lifshitz T. Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage. Eye (Lond). 2004 Mar;18(3):253-6. doi: 10.1038/sj.eye.6700632. PMID: 15004573.

  3. Kuzmanović Elabjer B, Bušić M, Bišćan Tvrdi A, Miletić D, Bosnar D, Bjeloš M. Ultrasound reliability in detection of retinal tear in acute symptomatic posterior vitreous detachment with vitreous hemorrhage. Int J Ophthalmol. 2017 Dec 18;10(12):1922-1924. doi: 10.18240/ijo.2017.12.21. PMID: 29259914; PMCID: PMC5733523.

  4. Gottlieb M, Holladay D, Peksa GD. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2019 Aug;26(8):931-939. doi: 10.1111/acem.13682. Epub 2019 Feb 5. PMID: 30636351.

  5. Kilker, B. A. , Holst, J. M. & Hoffmann, B. (2014). Bedside ocular ultrasound in the emergency department. European Journal of Emergency Medicine, 21 (4), 246-253. doi: 10.1097/MEJ.0000000000000070.

  6. Roque PJ, Hatch N, Barr L, Wu TS. Bedside ocular ultrasound. Crit Care Clin. 2014 Apr;30(2):227-41, v. doi: 10.1016/j.ccc.2013.10.007. Epub 2013 Dec 12. PMID: 24606775.

Emergency Medicine, Opthalmology, Radiology, UltrasoundChristian KeenanEmergency Medicine, Ophthalmology, pocusComment