Critical Cases - Painless Vision Loss (With Awesome Eye Ultrasound!)

Chief Complaint: Vision Loss left eye X 4 days



  • 35 yo male with pmhx of NIDDM reports 4 days of persistent, gradually worsening loss of vision in his left eye
  • Reports a portion of his visual field is severely blurry
  • Denies any eye redness or pain, no history of trauma
  • He is a contact lens wearer and occasionally keeps contacts in overnight
  • No eye discharge
  • No "flashes and floaters"
  • No headaches or neck pain


  • Eyes are grossly normal in appearance bilaterally
  •  Visual acuity: 20/30 OD, finger counting OS
  • EOM are intact
  • No afferent pupillary defect in either eye
  • Intra-ocular pressure measured by iCARE device = 13 mm Hg OD and OS
  • Fluorescin stain is negative
  • There is a left nasal inferior quadranopsia present on confrontation testing (patient cannot see anything in this quadrant)






Key Image:



Red arrows = detached retina tethered to optic nerve

Blue arrow = optic nerve


Differential diagnosis

  • The ultrasound images raise two primary differential diagnoses: retinal detachment and vitreous detachment
  • Both RD and VD have similar ultrasound findings: a thin echogenic "ribbon" floating in the middle of the globe
  • The key distinction is to observe the "ribbon" around the optic nerve: as the retina is contiguous with the optic nerve sheath, the ribbon appears "tethered" to the optic nerve in retinal detachment
  • See above key image: the echogenic ribbon appears to insert on the optic nerve, confirming retinal detachment


  • An acute retinal detachment is an opthalmological emergency: consultation in the ED or same-day visit to an opthalmologist is warranted
  • Urgent laser therapy or cryotherapy to "re-stick" the retina to the retinal epithelium is the treatment of choice
  • This requires a retina specialist