COTW 10/23/22 58M hx L eye blindness, htn, herpes zoster pw painless visual changes

58 yo male hx of legal blindness in L eye, prior bilateral orbital floor repair following a traumatic injury in his 20s, htn, herpes zoster presenting with 2 days of progressive peripheral vision loss in his left eye. Is legally blind in his left eye and describes vision as “fuzzy” at baseline but states things now seem darker particularly in the periphery. +headaches; no photophobia, eye pain, discharge, swelling, nausea, vomiting.

Vitals: BP 174/101, HR 82, 99% on RA, afebrile

Visual acuity: OD (right eye): 20/15; OS (left eye): can’t read chart - baseline 20/200; OU (both eyes): 20/15

Slit lamp exam: no cells or flare in anterior chamber, no foreign bodies or lesions, fluorescein staining without uptake or pooling.

Reported to have mildly diminished peripheral vision in left eye compared to right. PERRL, conjunctiva normal, eye exam otherwise unremarkable.

Ultrasound of left eye showing retinal detachment with probably vitreous hemorrhage

Quick ocular ultrasound shows you the image above and you diagnose a retinal detachment with vitreous hemorrhage. You know this is a retinal (and not a vitreous) detachment because you remember the retina is a thick, cord like structure that will remain attached to the optic nerve (does not cross midline). Vitreous detachment will be thinner and less hyperechoic in appearance, will demonstrate what’s call a “swaying seaweed” or “washing machine sign” in which the vitreous layer is loosely attached and does cross midline. You may have to increase the gain to see some subtle VDs.

Ocular ultrasound demonstrating vitreous detachment - a thinner structure, swirling around within the vitreous body, not attached to midline

Your next question: Is this mac-on or mac-off (ie is the macula already detached)?

Why is this important?

The macula is a small portion of the retina located in the posterior aspect of the eye on the temporal (lateral) side of the optic nerve that is primarily responsible for central, high resolution, and color vision. Patients with “mac-on” retinal detachment are candidates for more emergent surgical fixation of the RD as the damage to this portion of they eye has not yet occurred.

Assuming the probe marker is towards our patient’s nose, is this mac-on or mac-off? A second video is shown below:

Retinal detachment, mac-on or mac-off?

You correctly identify this as a mac-on retinal detachment, you emergently consult ophthalmology and the patient is taken repair the following day.

Shout out to Dr. Eurick for the great save!

Check out this great Ocular ultrasound pocket guide from POCUS 101 for future reference.