Acute non-traumatic visual decline in a patient.

CASE PRESENTATION

A 43‐year‐old homeless man with a history of poorly controlled diabetes and diabetic retinopathy presented with sudden painless vision loss of his right eye. On examinaton, the patient's visual acuity was limited to the identification of colors and hand motions on the right. A pan‐optic fundoscopic examinaton was very limited, and multiple physicians were unable to fully interrogate the retina. Point‐of‐care (POC) ocular ultrasound showed a mobile hyperechoic membrane from the ora serrata to the posterior globe that appeared to cross the optic nerve along with a triangular shaped hyperechoic area just anterior to the optic nerve.

DIAGNOSIS

Proliferative diabetic retinopathy with diabetic macular edema along with vitreous hemorrhage

The development of a vitreous hemorrhage in patients with diabetic retinopathy, if left untreated, predisposes to retinal detachments and subsequent inflammatory changes and blindness. As such, the need for rapid diagnosis and treatment of vitreous hemorrhages either with a vitrectomy or anti‐vascular endothelial growth factor (VEGF) injections cannot be overstated. A 2019 multicenter study illustrated the utility of POC ocular ultrasound when evaluating patients with painless loss of vision. Sensitivities for retinal detachment, vitreous detachment, and vitreous hemorrhage were 97%, 82%, and 43%, respectively. Although sensitivity for vitreous hemorrhages was low, specificity was high (96%). Ocular ultrasound (Video S1) was particularly helpful in narrowing the differential diagnosis in this patient, where a fundoscopic examination was limited. In this case, the ocular ultrasound (Figures 1 and 2) was concerning for a retinal detachment, masquerading as a vitreous hemorrhage, leading to an emergency department consult and subsequent urgent follow‐up with ophthalmology, where he was immediately started on anti‐VEGF intravitreal injections. In a patient without diabetic retinopathy, a vitreous hemorrhage can be seen on a non‐urgent outpatient basis by ophthalmology, whereas a retinal detachment requires emergent action.

FIGURE 1

Ultrasound showed a mobile hyperechoic membrane (arrows) that crossed the optic nerve (star)

FIGURE 2

Mobile hyperechoic membrane (arrow) from the ora serrata (diamond) to the posterior globe with a triangular shaped hyperechoic area (arrow head) just anterior to the optic nerve (star)

Supporting information.

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