Intern Ultrasound of the Month: Vitreous Hemorrhage
The Case
75-year-old male with a past medical history of type 2 diabetes, hypertension, and stroke with residual dysarthria presented to the emergency department for painless vision changes in his right eye. Two hours prior to arrival he experienced sudden loss of vision in his right eye while watching TV. He also reported flashes and floaters since that morning, which were initially intermittent before becoming constant. In addition, he reported a history of dry eyes and wears glasses but denied any history of similar symptoms. Also denied eye pain, trauma, falls, fevers, chills, chest pain, nausea, vomiting, and headache.
Ocular point-of-care ultrasound was indicated given his painless vision loss to evaluate for retinal detachment, vitreous detachment, and vitreous hemorrhage.
Figure 1.. Transverse views of the patients affected eye
POCUS Findings:
There is significant vitreous hemorrhage indicated by the mobile echogenic debris in the posterior chamber with no relation to the optic nerve. These images display the “washing machine sign” with attempts at a kinetic exam, though eye movement was limited due to patient ability. There does not appear to be any evidence of a retinal or vitreous detachment.
Case Conclusion:
The patient was evaluated by ophthalmology, and vitreous hemorrhage was confirmed. Ophthalmology recommended follow-up in their clinic in the morning and he was discharged home with a plan for close monitoring.
Vitreous Hemorrhage: Pathophysiology & Clinical Significance
Vitreous hemorrhage is the extravasation of blood into the vitreous chamber, which occurs secondary to three mechanisms, including abnormal vessels, rupture of vessels, and blood from an adjacent source. Abnormal vessels are typically due to ischemic diseases including diabetes, sickle cell disease, or retinopathy of prematurity. Rupture of vessels can occur with significant trauma overcoming the structural integrity of a vessel. Blood from adjacent sources can occur from retinal macroaneurysms or malignancy [1].
Common symptoms of vitreous hemorrhage include painless floaters, shadows, haziness, or other vision changes [1]. The diagnosis is typically made through a comprehensive ophthalmologic examination, though ultrasound is a useful adjunct that can help expedite the diagnosis [2-3].
Close follow-up with ophthalmology is recommended, as complications of persistent vitreous hemorrhage include glaucoma, retinal damage, and loss of vision. Possible definitive treatment for persistence of vitreous hemorrhage includes vitrectomy [4]. Timing of vitrectomy varies based on the etiology of the vitreous hemorrhage [1].
Ocular Point-of-Care Ultrasound
Materials
High frequency linear probe
Tegaderm to cover eye
Ultrasound gel
Technique for Ocular Ultrasound
Place a Tegaderm over the patient’s eye, being careful to avoid air pockets. Generously apply ultrasound gel to the high frequency linear transducer. Select the superficial preset for the probe. Place the probe gently over the patient’s closed eyelid with the probe marker facing the patient’s right side, using the patient’s nasal bridge or zygoma as a stabilizing point for the hand holding the probe. Ensure the probe is fully contacting the patient’s eye but apply as little pressure as possible to maximize the patient’s comfort [5-7].
Figure 2. Probe Placement [5]
Figure 3. Probe placement and eye anatomy [7]
Start with a normal gain setting to visualize the anterior chamber and posterior segment of the eye. Fan through the eye in the transverse position, identifying key structures. Significant posterior structures of the eye for a POCUS exam include the vitreous body, retina, and optic nerve. Make sure you have adequate depth to allow for visualization of these structures. If you do not initially see the optic nerve, slowly adjust the probe until it comes in to view. This is important because key pathology, i.e. retinal detachment and vitreous detachment, is differentiated by their relation to the optic nerve.
Slowly increase gain to optimize visualization of abnormalities within the vitreous body, particularly vitreous hemorrhage and detachment [5-7]. A study conducted by Chang et al. noted that high gain settings (75, 100 on scale of 0 to 100) had a higher sensitivity for detecting posterior chamber abnormalities compared to low gain levels [8].
Next, perform a dynamic exam (also known as oculokinetic echography, see Figure 5) where the patient looks left and right (or medial and lateral). This can help distinguish pathology that may not be clearly identifiable with a static image alone [5-7].
Figure 4. Fanning through the orbit
Figure 5. Dynamic exam or oculokinetic echography
Figure 6. Optic nerve
In addition to a transverse view, it’s also helpful to assess the globe with the probe in a longitudinal orientation. The process is similar to that of a transverse view, with the exception of asking the patient to look up and down for the kinetic exam [6,7].
Evaluate for Key Pathology: Retinal Detachment, Vitreous Detachment, Vitreous Hemorrhage
Retinal detachment can often be visualized in normal or even low gain settings and appears as a hyperechoic membrane that attaches posteriorly at or near the optic nerve. The membrane moves with eye movement but remains tethered to the optic nerve. Vitreous detachment, on other hand, presents as a (usually thinner) hyperechoic membrane that does NOT attach near the optic disc. It often crosses midline and moves more freely with a dynamic exam, having a “swaying seaweed” appearance (Figure 3). Vitreous hemorrhage appears as diffuse hyperechoic opacities that will appear as a “washing machine” sign on dynamic exam. As mentioned above, increasing the gain will often optimize visualization of vitreous hemorrhage and detachment [5-7].
Figure 7. Retinal detachment
Figure 8. Vitreous detachment
Figure 9. Vitreous hemorrhage
Utility of Ocular POCUS & Why Incorporate It Into Your Clinical Practice
Ocular chief complaints represent 2-3% of all emergency department visits [9]. Ocular ultrasound has been utilized by ophthalmologists for many years and is recognized as a useful adjunct to a comprehensive ophthalmologic exam [2]. More recently, emergency providers have been using ocular POCUS to promptly detect and differentiate ophthalmologic emergencies (e.g. retinal detachment) from less emergent pathology (e.g. vitreous detachment and hemorrhage). A study published in JAMA by Lanham et al. found that POCUS performed by emergency providers had 97% sensitivity and 88% specificity for retinal detachment, sensitivity and specificity of 82% for vitreous hemorrhage, and 96% specificity and 43% specificity for vitreous detachment [2]. A systematic review and meta-analysis by Propst et al., published in JAMA in 2020, similarly demonstrated high sensitivity and specificity for retinal detachment (both 94%) with slightly higher sensitivity and specificity for vitreous hemorrhage at 90% and 92%, respectively. Vitreous detachment again had poor sensitivity but specificity remained relatively high [3]. Overall, these studies suggest that ocular POCUS is a good diagnostic test for the more imminently vision-threatening retinal detachment and can be a useful diagnostic adjunct for vitreous hemorrhage and vitreous detachment. It can help expedite the diagnosis and determine urgency for ophthalmology evaluation.
Similar to other POCUS applications, focused ocular ultrasound can be completed within minutes at the bedside and is also relatively easy to learn. A study by Lazarow et al. evaluated the ultrasound skills of emergency medicine residents and pediatric emergency medicine fellows before and after a didactic and practical intervention. They found that after only brief instruction and hands-on training, participants showed significant improvement in their subjective and objective ocular ultrasound knowledge as well as in their ability to diagnose ocular pathology with ultrasound [10]. Another study by Kang et al. compared online ocular ultrasound education with hands-on education and found non-inferiority of the latter, offering a potential alternative method for learning [11].
Take Home Points
Ocular ultrasound can be performed at the bedside for prompt evaluation of several ocular pathologies, including retinal detachment, vitreous detachment, and vitreous hemorrhage.
Vitreous hemorrhage appears sonographically as hyperechoic opacities swirling ( “washing machine” sign) in the vitreous during an oculokinetic exam.
Vitreous detachment presents as a mobile hyperechoic membrane not attached to the optic nerve (and can cross midline) that tends to be more freely mobile during an oculokinetic exam.
Retinal detachment is an ophthalmologic emergency that presents as a mobile hyperechoic membrane that remains attached posteriorly to the optic nerve with oculokinetic ultrasonography. Of these three pathologies, the diagnostic utility of POCUS is highest for retinal detachment.
Ocular ultrasound does not replace a comprehensive ophthalmologic exam but can help expedite diagnosis, determine the urgency of evaluation by ophthalmology, and can be easily learned in various settings.
POST BY: MATTHEW HOM, MD (PGY2)
FACULTY EDITING BY: LAUREN MCCAFFERTY, MD
References
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Lahham S, Shniter I, Thompson M, et al. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Netw Open. 2019;2(4):e192162.
Propst SL, Kirschner JM, Strachan CC, et al. Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(2):e1921460.
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Dinh V. Ocular Ultrasound made easy: Step-by-step guide. POCUS 101. Accessed July 19, 2023. <https://www.pocus101.com/ocular-ultrasound-made-easy-step-by-step-guide>
Chang M, Finney N, Baker J, et al. Optimal Image Gain Intensity of Point-of-care Ultrasound when Screening for Ocular Abnormalities in the Emergency Department. West J Emerg Med. 2023;24(3):622-628.
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Lazarow F, Deal AK, Shaves SC, et al. Evaluation of a point-of-care ultrasound curriculum and ocular phantom in residency training. J Ultrasound. 2022;25(2):259-263.
Kang SY, Yoo J, Park S, et al. Online Learning versus Hands-On Learning of Basic Ocular Ultrasound Skills: A Randomized Controlled Non-Inferiority Trial. Medicina (Kaunas). 2022;58(7):960.