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Retinal Detachment and Other Uses of B-scan in the Emergency Room




Retinal detachment is an ophthalmologic emergency that can result in severe loss of vision. A variety of

etiologies exist for this condition, including proliferative diabetic retinopathy, penetrating trauma,

advancing age, serous fluid accumulation in inflammatory eye pathology, and a complication after cataract

surgery . Direct observation of a detached retina can be impeded by a variety of factors, including an

associated large vitreous hemorrhage, narrow anterior angle precluding mydriatic application, periorbital

trauma, or lens opacification. In the aforementioned cases, and others, ocular ultrasonography can be

used to delineate underlying pathology of visual symptoms. 


Because ocular emergencies represent 3% of all ED encounters, existing constraints to CT/MRI of the orbit

 including time and cost, and variable availability of ophthalmologists, emergency practitioner comfort with

ocular ultrasound is important. To use B-scan for evaluation of retinal detachment cases in the emergency

room, Teismann et al. recommend the mnemonic CASE.

1) Close and cover the eye with gel

2) Axial plane: apply the transducer gently on the eye with your fourth and fifth fingers resting on the

patient’s nose.

3) Scan the retina for pathology. A normal appearing retina should be continuous. If detachment is present,

fluid will begin to separate the retinal epithelium its attachment to the globe. This will create a thick, oscillating,

 hyperechoic structure in the case of retinal detachment.

4) Evaluate the entire eye: small retinal detachments can occur in the retina periphery. The patient may have

to move his or her eyes while you are scanning to ensure visualization is complete.

Other forms of eye pathology can appear similar on ultrasonography, including posterior vitreous detachment

and vitreous hemorrhage. If retinal detachment is suspected based on imaging or clinical history, referral should

be made to ophthalmology within 24 hours, as noted above .


Research has shown that bedside ultrasound in the ED can be effectively used for the diagnosis of ocular

pathology, as exemplified by Blaivas et al., 2002. In this study, 61 patients presenting with ocular trauma or

acute visual changes within 48 hours of symptom onset underwent B-scanning. Patients with binocular

symptoms indicative of neurologic pathology were excluded. Bedside ultrasound images were analyzed for

presence of vitreous hemorrhage or detachment, retinal detachment, central retinal artery and vein

occlusion (by Doppler ultrasound), globe rupture, intraocular foreign bodies, lens dislocation, and retrobulbar

 hematomas. Results were compared to a gold standard of CT of the orbit, ophthalmologist diagnoses, or

both. In 60/61, nearly 100% of patients included in the study, the ED ultrasound results were confirmed by

gold standard. As such, ocular ultrasound modalities are likely to serve as useful adjuncts in cases where

ophthalmology consults are delayed. Of course, care should be taken to avoid vitreous fluid leakage in cases

 of penetrating eye injury, and caution should be exercised when applying ultrasound equipment to the eye.

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