Your next patient is a young African-American female with no history of sickle cell disease, ocular conditions, or any other medical problems. She was triaged with a chief complaint of “floaters” in her right eye. She tells you she developed the floaters after coughing very hard the previous night. She thought it would be better this morning, but things have not really changed. She denies any trauma, pain, flashing lights or cobwebs, and states that what she really has is one big floater right in the middle of her vision making it hard to see with that eye.

Physical examination is essentially normal except for a few ocular findings. Inspection of the external eye is normal and pupils are equal and reactive without photophobia. On close inspection, she appears to have a very mild afferent pupillary defect (APD). Fields of vision are full when checked in each eye independently, but visual acuity is worse than 20/200 in the affected eye with best performance being finger counting at 5 feet. On fundoscopic exam, you see the normal retinal red reflex, but despite adjusting the lens of the ophthalmoscope, you cannot get a clear view of the optic nerve or retinal vessels. In the good eye, you are able to visualize a nice, normal retina, optic disc, macula, and retinal vessels.

Prior to calling the ophthalmologist, you decide to scan the eye with your ED ultrasound machine to see if you can pick up any abnormalities. Using the linear array transducer and a generous amount of ultrasound gel over a CLOSED eyelid, you obtain the following image. What do you think it shows?

What does the ultrasound show?  Conclusion on next page




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