Blind drunk – unilateral

Do you have a Breakfast Club in your ED.  In our ED it is commonplace to see 2 – 3 drunk, head-injured patients sleeping it off and having “neuro obs” until the cornflakes and tea are served – followed by spontaneous discharge.  This “ward round”is usually pretty mundane, sometimes a few sutures etc.

But last week I saw something new – blindness, acute left eye loss of vision following a punch to the head (not a first time attender).  This made me ponder the possible differentials.  External exam was pretty much NAD, so what is the cause?  This is the list I came up with for this scenario:

Retinal detachment, vitreous bleed, traumatic cataract, occult foreign body, lens disloation, post-traumatic optic neuropathy, vascular injury / dissection (carotid or vertebral), transient cortical blindness, retrobulbar haematoma…  as you can see a big differential, anyone else think of any causes not obvious on exam?  In terms of probability the first 3 (underlined) are the big ones.

Anyway – I have a confession – I am pretty crappy with an ophthalmoscope.  So in this situation I reach for the linear high-frequency US probe.  If you have never done this – it is the easiest USS in the book, just plonk the probe on the upper lid and waft it up and down.

This image is from the guys at Ultrasound Village.  Check out their site and courses.

Shows the typical retinal detachment – floating retina anchored at the disc posteriorly.  Acutely htis will move as the patient moves the globe, however after a while it tends to fix in one place.  Can be differentialted from a vitreal bleed by asking the patient to look up and down and checking the änchor point”is fixed at the disc – not floating / or rolling.

In my practice the US has made eye assessment sooo much easier.  I reckon I can confidently exclude a detachment using US much easier than with the scope, and with the US you can get right around to the anterior part of the retina – I find tis impossible with the opthalmoscope.  You can also see a FB easily and the blood in a vitreal bleed is easy.  I have not seen a lens dislocation with this – so cannot comment.

Anyway my patient had the classic left-eye-blind ((R) handed assailant) of a traumatic retinal detachment and she was seen by the visiting Eye guys – unfortunatley she had had this for a bit longer than she was originally letting on and there was little chance of a fix