Clark, Christopher R

Holbrook, Michael B

Kaitis, Daniel

Van Laere, Jeffrey

Van Laere, Lily

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Emergency Medicine Articles Emergency Medicine 5-22-2020 Retinal detachment with subretinal and vitreous hemorrhages causing secondary angle closure glaucoma diagnosed with ultrasound Michael B. Holbrook Daniel Kaitis Lily Van Laere Jeffrey Van Laere Christopher R. Clark Follow this and additional works at: https://scholarlycommons.henryford.com/emergencymedicine_articles Retinal detachment with subretinal and vitreous hemorrhages causingsecondary angle closure glaucoma diagnosed with ultrasoundMichael B. Holbrook, MD, MBA a,⁎, Daniel Kaitis, MDb, Lily Van Laere, MDb,Jeffrey Van Laere, MD, MPHa, Chris Clark, MD aa Henry Ford Hospital, Department of Emergency Medicine, Detroit, MI, United States of Americab Henry Ford Hospital, Department of Ophthalmology, Detroit, MI, United States of AmericaA 90-year-old female with a past medical history of trigeminal neu-ralgia and age-related macular degeneration (AMD) presented with afour-day history of a left-sided headache, nausea, and vomiting. Regard-ing her left eye, she reported intermittent flashes of light over the pastmonth and complete vision loss for four days. She denied a history of di-abetes, hypertension, anticoagulant use, or ocular trauma. Her ocularhistory included the use of reading glasses and bilateral cataract surgeryforty-five years ago.She was unable to describe the vision in her left eye prior to symp-tom onset, stating that “it has been blurry for a while”. She was uncom-fortable. Her left eye was diffusely injected with a cloudy cornea and afixed, mid-dilated, and non-reactive pupil. The vision in her unaffectedright eye was 20/200 with an intraocular pressure (IOP) 16 mmHg;her left eye had no light perception (NLP) with an IOP of 56 mmHg.She was immediately started on an IOP-lowering regimen ofdorzolamide, brimonidine, and latanoprost; ophthalmology wasemergently consulted. A bedside ultrasoundwas performed by anultra-sound fellowship-trained emergency medicine physician using a high-frequency linear probe on a Sonosite X-porte. The scan demonstrateda large area ofmixed echogenicitywithin the subretinal space and vitre-ous cavity consistentwith both subretinal and vitreous hemorrhages. Inaddition, there was a flap tethered to the optic nerve concerning for anassociated retinal detachment.On slit lamp examination, the ophthalmologist noted the left ante-rior chamber to be flat with a bulging iris and a detached retina, visiblethrough the pupil through the posterior chamber. The right eye showedgeographic atrophy, consistent with AMD. Given a concern for alteredmental status, a CT head without contrast was performed, which dem-onstrated lentiform hyperdensities within the left globe which ap-peared to converge at the optic disc, concerning for a hemorrhagicretinal detachment.The patient was admitted with concern for secondary acute angleclosure glaucoma. Her medication regimen was continued with the ad-dition of prednisolone acetate and atropine, 8 h after initial triage.Whileinpatient, she noted continued headaches, refractory to home carba-mazepine. An MRI orbit with and without contrast was performed, re-vealing blood products in the left globe and irregularity of thechoroid/retina consistent with a retinal detachment. Her pain was con-trolled with oral hydrocodone/acetaminophen. Ultimately her visionwas deemed unsalvageable given her age, length of symptoms, andlack of light perception. At time of discharge, her left eye's IOP was49 mmHg.Acute angle-closure glaucoma (AACG) occurs when there is insuffi-cient aqueous humor outflow from the anterior chamber through thetrabecular meshwork due to mechanical obstruction. Symptoms classi-cally can be precipitated by dilating the pupil, either through physio-logic means or medications, such as sympathomimetics oranticholinergics.Hemorrhagic retinal detachment precipitating AACG has classicallybeen associated with AMD, anticoagulant use, hypertension, diabetesmellitus, and trauma [1,4-7,10].Both subretinal and vitreous hemorrhages can induce secondaryAACG, increasing the pressure in the posterior segment of the eye,thereby causing anterior displacement of the lens/iris diaphragm [3,5].An increase in the posterior segment pressure pushes the vitreous andthe lens forward, closing the angle, and precipitating angle closure glau-coma [9]. Atropine can serve as an adjunct medication in cases of AACGsecondary to increased posterior segment pressures.Atropine relaxes the ciliary body, creating a dilatory effect on thepupil that is classically contraindicated in primary AACG; the pupil's di-lation further closes the angle, delaying aqueous humor outflow, andexacerbating IOP. In secondary AACG, this ciliary body relaxation, how-ever, can posteriorly displace the lens and can aid in lowering IOP.Point-of-care ultrasound can be performed quickly without need fora consult service, is inexpensive, and has repeatedly shownno increasedrisk of radiation to the patient [8]. In a systematic review and meta-analysis by Gottlieb et al., ultrasound was found to be 94% sensitiveand 96% specific for the diagnosis of retinal detachment;moreover, sub-group analysis found no statistical significantly differences when com-paring scans from emergency department (ED) providers to non-EDproviders [2]. Additionally, while CT and MRI can aid in the diagnosis,studies have shown that they have poorer spatial resolution and canhave limited role in the study of the vitreous, retina, and choroid [1].Overall, the visual prognosis is extremely poor with secondaryAACG. Reversal of anticoagulation should be initiatedwhen appropriate.Early surgical repair (laser/open iridotomy or sclerotomy with evacua-tion) or enucleation for pain control serve as further, more definitivemeasures.American Journal of Emergency Medicine xxx (xxxx) xxx⁎ Corresponding author.E-mail address:mholbro1@hfhs.org (M.B. Holbrook).YAJEM-159017; No of Pages 2Contents lists available at ScienceDirectAmerican Journal of Emergency Medicinej ourna l homepage: www.e lsev ie r .com/ locate /a jemPlease cite this article as: M.B. Holbrook, D. Kaitis, L. Van Laere, et al., Retinal detachment with subretinal and vitreous hemorrhages causingsecondary angle closure glaucoma..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2020.05.050https://doi.org/10.1016/j.ajem.2020.05.0500735-6757/© 2020 Elsevier Inc. All rights reserved.Downloaded for Anonymous User (n/a) at Henry Ford Hospital / Henry Ford Health System (CS North America) from ClinicalKey.com by Elsevier on August 17, 2020.For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.Conflicts of interest and sources of fundingNo external funding was secured for this manuscript.The authors have no financial relationships or conflicts of interest todisclose.Appendix A. Supplementary dataSupplementary data to this article can be found online at https://doi.org/10.1016/j.ajem.2020.05.050.References[1] Chen SN, et al. Acute angle-closure glaucoma resulting from spontaneous hemor-rhagic retinal detachment in age-related macular degeneration: case reports and lit-erature review. Jpn J Ophthalmology. 2001;45(3):270–5 May-June. [PMID11369377].[2] Gottlieb M, Holladay D, Peksa GD. Point-of-care ocular ultrasound for the diagnosisof retinal detachment: a systematic review and meta-analysis. Acad Emerg Med.2019;26(8):931–9 Aug 26. [PMID: 30636351].[3] Lee YJ, Kang SM, Kang IB. Acute angle-closure glaucoma from spontaneous massivehemorrhagic retinal detachment. Korean J Ophthalmol. 2007;21(1):61–4.[4] Liu YC, Lau LL, Lee FL, Ko YC, Hsu WM. Recurrent acute angle-closure attacks in age-related macular degeneration-associated massive posterior segment hemorrhage.Jpn J Ophthalmol. 2009;53:190–1.[5] Masri I, et al. A rare case of acute angle closure due to spontaneous suprachoroidalhaemorrhage secondary to loss of anti-coagulation control: a case report. BMCOphthalmol. 2018;18(Suppl. 1):224.[6] Pesin SR, et al. Acute angle-closure glaucoma from spontaneous massive hemor-rhagic retinal or choroidal detachment. An updated diagnostic and therapeutic ap-proach. Ophthalmology. 1990;97(1):76–84 Jan. [PMID 2179799].[7] Sosuan GMN, Domingo RED. Acute angle closure glaucoma from spontaneous mas-sive subretinal hemorrhage. GMS Ophthalmol Cases. 2019;9. https://doi.org/10.3205/oc000104 Doc15. April.[8] O’Brien AJ, Brady RM. Point-of-care ultrasound in paediatric emergency medicine. JPaediatr Child Health. 2016;52(2):174–80 Apr.[9] Williams GS, Anderson L, Eddyshaw D. Macular hemorrhage as a cause of acuteangle closure. Indian J Ophthalmol. 2013;61(11):683–4 Nov.[10] WoodWJ, Smith TR. Senile disciformmacular degeneration complicated by massivehemorrhagic retinal detachment and angle closure glaucoma. Retina. 1983;3(4):296–303 Fall-Winter.2 M.B. Holbrook et al. / American Journal of Emergency Medicine xxx (xxxx) xxxPlease cite this article as: M.B. Holbrook, D. Kaitis, L. Van Laere, et al., Retinal detachment with subretinal and vitreous hemorrhages causingsecondary angle closure glaucoma..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2020.05.050Downloaded for Anonymous User (n/a) at Henry Ford Hospital / Henry Ford Health System (CS North America) from ClinicalKey.com by Elsevier on August 17, 2020.For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Retinal detachment with subretinal and vitreous hemorrhages causing secondary angle closure glaucoma diagnosed with ultrasound

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Retinal detachment with subretinal and vitreous hemorrhages causing secondary angle closure glaucoma diagnosed with ultrasound

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