Chief Complaint: Vision Loss left eye X 4 days

HPI

• 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

Exam

• 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)

Ultrasound

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

Management

• 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