It’s always a balancing act of knowing when to eat on shift. You’re hypoglycemic, but you just saw a patient with gastroenteritis. You’ve got to wash your hands and grab a quick snack before you syncopize or get gastro! On a particularly busy shift, I was starting to see spots from being so hungry. I took a few bites of my bagel with egg whites and cheese, chugged a Dunkin’ Donuts coffee, threw it all in my bag before the head nurse could see, and then ran in to see my next patient.
90 year-old female brought in by EMS for sudden painless loss of vision in her right eye. What is your differential? -Central retinal artery occlusion -Central retinal vein occlusion -Stroke -Posterior uveitis -Optic neuropathy -Retinal Detachment The posterior segment of the eye is a large cavity filled with vitreous gel. Natural aging causes contraction of vitreous gel and separation from the posterior wall of the eye. However, when vitreous pulls the retina enough to cause a defect in the retinal attachment, fluid will accumulate and cause the retina to slowly peel off, leading to retinal detachment (RD). What are the causes of RD? The origin of most retinal detachments is a retinal tear, caused by: -Normal aging process -Severe nearsightedness -Posterior vitreous detachment -Prior eye trauma or surgery What are the signs and symptoms of RD? -Flashes of light/photopsia caused by retinal tugging (unilateral in affected eye) -Floaters (shadows cast by vitreous gel) -Painless monocular vision loss -A dark veil or curtain in the peripheral field of vision that progresses to the center over hours to weeks -Decreased peripheral and/or central visual acuity -Blurry vision What other conditions present with floaters? -Posterior vitreous detachment -Proliferative diabetic retinopathy What other conditions present with flashes? -Posterior vitreous detachment –Ophthalmic migraines with or without aura (binocular) -Optic neuritis -Postural hypotension (binocular) -Vasovagal reactions (binocular) -TIA What is the most common location for a retinal tear? Peripheral retina (where retina is thinner). This is not visualized on a direct fundoscopic examination! How do we diagnose it in the ED? Bedside ultrasound (US) with a high frequency linear probe is the fastest method for diagnosis in the ED. The eye is circular and hypoechoic on US. The detached retina will be seen as a hyperechoic stripe at the bottom of the screen floating in the anechoic posterior chamber. See this ALiEM blog post for more info. What is the treatment? -If retinal detachment is diagnosed in the ED by ultrasound or clinical presentation, refer the patient to an Ophthalmologist within 24 hours for prompt surgical repair. You can have flashes and floaters without retinal detachment, but you cannot have retinal detachment without flashes and floaters. Prompt ophthalmologic evaluation is therefore important to differentiate benign from pathologic. So next time you see a patient with floaters and flashes of light, be sure to ask about timing and any changes, especially in the context of vision loss. Any new flashes and floaters with vision changes should be alarming. -Retinal tears and retinal detachment usually affect the elderly, but they can occur in severely nearsighted young people -Bedside ultrasound in the ED is the fastest and most accurate method for diagnosis -Time is of the essence. The faster the recognition of a retinal tear, the sooner you can refer to a specialist for treatment, and the more likely that vision can be preserved. Tintinalli, Judith E., J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D. Meckler, and David M. Cline. Tintinalli’s Emergency Medicine a Comprehensive Study Guide. New York: McGraw-Hill Education, 2016. Print. Rosh Review https://www.aliem.com/2010/10/retinal-detachment-on-ultrasound/ https://www.acep.org/Clinical—Practice-Management/Focus-On–Ultrasound-for-Acute-Retinal-Detachment/ http://www.aafp.org/afp/2004/0401/p1691.html What is retinal detachment?
Back to your differential diagnosis:
How do we know the difference between benign flashes and floaters vs. retinal detachment?
Summary:
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