Gregory Eisinger, MD, MSSW; Michael Prats, MD; Stanley Park, MD; David Bahner, MD, RDMS. 0196-0644/$-see front matter. Copyright © 2017 by the ...
IMAGES IN EMERGENCY MEDICINE Gregory Eisinger, MD, MSSW; Michael Prats, MD; Stanley Park, MD; David Bahner, MD, RDMS 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.01.033
Figure. Left panel: Axial/transverse ultrasonography of a normal left eye with the anterior chamber (star), lens (short arrow), macula (long arrow), and optic nerve (asterisk) indicated. Right panel: Axial/transverse ultrasonography of the affected (right) eye, showing the vitreous as the central large dark space, with the red arrow indicating the area of submacular hemorrhage.
[Ann Emerg Med. 2017;70:e3-e4.] An 88-year-old man with history of wet macular degeneration presented with painless vision loss in his right eye. He had awoken with a central scotoma without other associated ocular or systemic symptoms. Visual acuity in the affected eye was light perception only, and the remainder of his ophthalmic and neurologic examination results were noncontributory, although his fundi were poorly visualized. Bedside ocular ultrasonography was performed for further assessment (Figure).
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DIAGNOSIS: Acute submacular hemorrhage. Bedside ultrasonography revealed elevation of the macular retina, with underlying thin hypoechoic fluid collection. Dilated funduscopic examination showed a corresponding large area of submacular hemorrhage. Submacular hemorrhage is a common cause of painless vision loss in patients with age-related macular degeneration. Diagnosis is typically made on funduscopic examination, which is difficult to perform reliably without the use of cycloplegic agents. Bedside ultrasonography can be helpful in identifying elevation of the retina caused by bleeding from the neovascularized choroid, although the sensitivity and specificity have not been reported.1,2 Similar features may also be observed with subretinal hemorrhage in pediatric patients presenting with nonaccidental head trauma.3 The differential diagnosis for these sonographic findings includes conditions such as retinal tumors, making the clinical context very important.2 Early diagnosis and referral to ophthalmology may lead to improved visual outcomes and identification of treatable neovascularization in the contralateral eye.1 Our patient consulted with ophthalmology the following day to begin intravitreous injections of the vascular endothelial growth factor inhibitor aflibercept. Author affiliations: From the Department of Emergency Medicine (Eisinger, Prats, Bahner) and Department of Ophthalmology (Park), Ohio State University. REFERENCES 1. Stanescu-Segall D, Balta F, Jackson TL. Submacular hemorrhage in neovascular age-related macular degeneration: a synthesis of the literature. Surv Ophthalmol. 2016;61:18-32. 2. Lorente-Ramos R, Arman J, Munoz-Hernandez A, et al. US of the eye made easy: a comprehensive how-to review with ophthalmoscopic correlation. Radiographics. 2012;32:175-200. 3. Riggs BJ, Trimboli-Heidler C, Spaeder MC, et al. The use of ophthalmic ultrasonography to identify retinal injuries associated with abusive head trauma. Ann Emerg Med. 2016;67:620-624.
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