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.
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
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact