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ULTRASOUND CASE REVIEW
Associate Editor: J. Kate Deanehan, MD, RDMS
Child With Red Eye and Blurry Vision
Joo Lee Song, MD, Marsha Elkhunovich, MD, and Jessica Hersman Rankin, MD
Abstract: Point-of-care ocular ultrasound can provide the clinician with
more information about potential intraorbital and extraocular pathology, especially in cases when direct visualization of the eye is limited. This case
report describes the findings in a pediatric patient who presented with a
1-month history of eye injection and worsening blurry vision. After pointof-care ultrasound demonstrated abnormal debris in the posterior vitreous
cavity, subsequent evaluation revealed a diagnosis of pars planitis.
Key Words: ultrasound, point-of-care ultrasound, ocular ultrasound,
pars planitis
(Pediatr Emer Care 2017;33: 703–705)
CASE
A 9-year-old previously healthy boy presented to the pediatric emergency department with injection of the left eye for
1 month. He reported associated mild blurry vision of the left
eye that became progressively worse. His primary doctor had
previously diagnosed him with conjunctivitis and prescribed
erythromycin ointment. He had no fevers, no trauma, and denied
any pain. He denied any discharge and had no prior history of
wearing glasses.
In the emergency department, he had normal vital signs for
age. On examination, his pupils were equal, round, and reactive
to light bilaterally. His extraocular movements were intact bilaterally, and the patient had no complaints of pain with eye movements. He was noted to have left eye injection without discharge.
There was no evidence of orbital swelling or erythema. The rest
of his physical examination was unremarkable. Visual acuity
was noted as follows: OD (Right Eye) 20/20, OS (Left Eye)
20/200, and OU (Both Eyes) 20/25.
A point-of-care ultrasound (POCUS) was performed by the
pediatric emergency medicine fellow (while precepted by the pediatric emergency medicine attending) to evaluate for possible
intraocular pathology, such as retinal detachment, intraocular
foreign body, or vitreous hemorrhage. The examination demonstrated abnormal debris in the posterior vitreous cavity (Fig. 1,
video 1, http://links.lww.com/PEC/A192).
Ophthalmology was consulted for further evaluation, who
confirmed that the patient had decreased vision. On their slit lamp
examination, there was presence of 2+ cells and trace flare (light
reflecting off increased protein content in the aqueous humor) in
the anterior chamber of the left eye, indicative of an inflammatory
From the Division of Emergency and Transport Medicine, Children's Hospital
Los Angeles, Keck School of Medicine, University of Southern California,
Los Angeles, CA.
Disclosure: The authors declare no conflict of interest.
Reprints: Joo Lee Song, MD, Division of Emergency and Transport Medicine,
Children's Hospital Los Angeles, Keck School of Medicine, University of
Southern California, 4650 Sunset Blvd, MS No 113, Los Angeles, CA
90027 (e‐mail: josong@chla.usc.edu).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.pec-online.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
process. The left iris was noted to have early signs of adhesions
between the iris and lens, otherwise known as posterior synechiae
formation. The patient was admitted for inpatient workup. After
infectious and rheumatologic evaluations were completed in the
inpatient setting, the patient was diagnosed with pars planitis
and began treatment with systemic steroids.
ULTRASOUND FINDINGS
Longitudinal, transverse, and dynamic views of both eyes
were obtained. Point-of-care ultrasound of the right eye demonstrated normal findings of the cornea, lens, anterior chamber, vitreous body, and posterior chamber. Point-of-care ultrasound of the
left eye demonstrated thin hyperechoic strands swirling in the posterior vitreous cavity along with a thick hyperechoic stalk anchored at the optic nerve centrally. Of note, the retina is most
firmly attached to the choroid at 2 distinct points: the optic nerve
head and at the junction of the retina and ciliary body known as
the ora serrata. Total retinal detachment produces a “V shape” of
FIGURE 1. Thin hyperechoic strands (thick arrow) seen swirling
in the posterior vitreous cavity. A thick hyperechoic stalk is seen
and appears to be anchored at the optic nerve (thin arrow)
head centrally, but not the ora serrata (star) laterally. In Figure 1,
the probe indicator is to the patient's left side, as demonstrated
in Figure 3.
Pediatric Emergency Care • Volume 33, Number 10, October 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
www.pec-online.com
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Pediatric Emergency Care • Volume 33, Number 10, October 2017
Song et al
views, the probe indicator should be pointing in the lateral direction (Fig. 3) to visualize the macula in the medial position. This
is particularly important to differentiate “mac on” retinal detachments (retina is detached but still attached at the macula, implying
that the visual center is still functional) compared with “mac off ”
retinal detachment (retina is detached and off the macula).4 Mac
on retinal detachment cases are the most emergent given the
potential for sight-sparing if timely corrective intervention is
instituted.4 The transducer should be fanned to obtain images
throughout the orbit. The ultrasound gain settings should be adjusted to better visualize the intraocular structures. If able to follow commands, the patient is then asked to move his or her eye
in all 4 planes, similar to assessing the patient's extraocular movements on examination, to obtain dynamic views of the vitreous
cavity. Normal structures can be visualized (Fig. 4), including
the iris, lens, vitreous body, retina, and optic nerve.
REVIEW OF THE LITERATURE
Pars planitis is an idiopathic form of intermediate uveitis
with the primary site of inflammation occurring in the vitreous humor.5 This results in the formation of inflammatory debris in the
vitreous cavity that can block vision or be described by patients
as “floaters” seen in their line of vision.5 This debris is characteristically described as “snowball formation” with sedimentation of
debris along the pars plana creating a “snowbanking” effect,
which can be seen on slit lamp examination.5 The pars plana is
the flat, posterior portion of the ciliary body that terminates at
FIGURE 2. Ocular POCUS technique demonstrating that the probe
indicator is up towards the head of the patient. The eye is then
scanned in the sagittal plane to obtain longitudinal views.
the hyperechoic floating material on ultrasound anchored at these
2 points.1 In the case of our patient, although the hyperechoic stalk
was anchored at the optic nerve, it was not anchored to the ora
serrata (Fig. 1, video 1, http://links.lww.com/PEC/A192).
TECHNIQUE
Point-of-care ultrasound can provide the clinician with more
information about potential intraorbital and even extraocular pathology, especially in cases when direct visualization of the eye
is limited. Kilker et al2 proposed a systematic approach to ocular
ultrasound using a “FOVEA” protocol for examining the key
structures with ultrasound: front of the eye, optic nerve, vitreous,
extraocular, artery/vascular.
Point-of-care ocular ultrasound is traditionally performed
using a high-frequency linear transducer.1 The patient may be
evaluated in his or her position of comfort, whether in a sitting
or supine position. Initial preparation includes instructing the patient to close the eye (if of age to follow commands) and placing
a clear plastic dressing (eg, Tegaderm) over the eye.3 It is important to prevent any air bubbles from being trapped underneath
the dressing because air can interfere with the images being obtained. Enough ultrasound gel should be applied over the entire
preorbital space and sufficient so that the transducer can float over
this gel layer, not requiring actual contact with the patient's eyelid.
This is particularly important in cases of increased intraocular
pressure or in cases of possible globe rupture.1 Alternatively, individualized sterile packets of petroleum jelly can be applied directly to the eye. The probe indicator is placed towards the top
of the patient's head for longitudinal views (Fig. 2). For transverse
704
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FIGURE 3. Ocular POCUS technique demonstrating that the probe
indicator is to the patient's left side. The eye is then scanned in the
transverse plane.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Pediatric Emergency Care • Volume 33, Number 10, October 2017
Child With Red Eye and Blurry Vision
intracranial pressure.8 Point-of-care ultrasound of the eye can be
used to assess a wide spectrum of intraocular pathologies including retinal detachment, vitreous hemorrhage, lens dislocation,
globe rupture, retrobulbar hematoma, intraocular foreign bodies,
periorbital abscess, or optic nerve swelling.1 In cases of inflammatory conditions affecting the vitreous and peripheral retina such as
intermediate uveitis or pars planitis, ultrasound findings resemble
those of vitreous hemorrhage, where there is increased echogenicity throughout the vitreous chamber.9 In cases of vitreous
hemorrhage, hyperechoic particles can be seen in the vitreous,
which may be better visualized by increasing the ultrasound gain
or having the patient look to all four quadrants.1 The presence of
mobile, membranous, echogenic strands in the vitreous cavity that
swirl with eye movement, as seen with this case, can be seen in
pars planitis, retinal detachment, subacute vitreous hemorrhage,
and acute and chronic posterior vitreous detachment10 and should
be further evaluated by ophthalmology.
CONCLUSIONS
Point-of-care ultrasound can be a useful tool for the evaluation
of children with eye complaints. This case highlights the utility of
POCUS for detecting signs of a less common ophthalmologic condition and prompted definitive consultation and management.
FIGURE 4. Point-of-care ultrasonography image of a normal eye.
Iris (thick arrow), lens (thin arrow), vitreous body (bracket), retina
(dotted arrow), and optic nerve width (x-x). In Figure 4, the probe
indicator is up pointing towards the head of the patient, as
demonstrated in Figure 2.
the ora serrata. Of note, the term pars planitis is reserved for cases
of intermediate uveitis when there is snowball formation or
snowbanking effect in the absence of an associated systemic or infectious disease.6 Patients with pars planitis may also report having eye injection and episodes of eye deviation. Pars planitis
typically affects children and adolescents and there is a male predominance.5,7 The disease process may affect one eye although
the course may progress to bilateral eye involvement.5 Complications of this condition can include optic disk edema, cataracts, vitreous hemorrhage, and cystoid macular edema.5,7 Treatment is
typically with intraocular or systemic steroids.5 With early diagnosis and appropriate therapy, visual prognosis is good.5,7 In this
case, views of the vitreous cavity provided information about the
presence of abnormal debris in this area, a key finding in pars
planitis patients, and led to further evaluation and management.
Point-of-care ocular ultrasound can be a useful adjunct to
clinical examination in pediatric patients with eye complaints. Indications for POCUS include orbital trauma, changes or loss in vision, eye pain, concern for intraocular foreign body, and increased
REFERENCES
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clinical features and outcomes. J Ophthalmic Vis Res. 2011;6:249–254.
8. Horowitz R, Bailitz J. Ocular ultrasound—point of care imaging of the eye.
Clinical Pediatric Emergency Medicine;16:262–268.
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Ultrasound CT MR. 2011;32:14–27.
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© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
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