A 63 year old male presents for “floaters” in his right eye for two weeks. He wears reading glasses at baseline. He denies pain or known injury to the eye. On exam, his visual acuity is 20/30 OD, 20/20 OS corrected with reading glasses. Pupils are equal, round, and reactive to light. IOP is 8 OD, 9 OS. There are no areas of focal uptake with fluorescein stain. POCUS of the right orbit is shown below. What’s the diagnosis?

Answer: Posterior Vitreous Detachment and Vitreous Hemorrhage (bright echogenic membrane horizontally across the posterior chamber not attached at the optic nerve and multiple free-flowing areas of varying hyperechogenicity that are mobile with eye movement)

• Presentation may vary from sudden onset floaters and generalized hazy vision to complete vision loss depending on severity
• May sometimes be a precursor to a retinal detachment
• Important to distinguish from a retinal detachment which will demonstrate a “V” shaped echogenic membrane attached to the optic nerve on POCUS
• Management is ophthalmology consultation especially if retinal detachment is suspected as it is a true ophthalmologic emergency

References:

Walker R.A., & Adhikari S (2020). Eye emergencies. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill. 

Lahham, S., Ali, Q., Palileo, B. M., Lee, C., & Fox, J. C. (2019). Role Of Point Of Care Ultrasound In The Diagnosis Of Retinal Detachment In The Emergency Department. Open access emergency medicine : OAEM, 11, 265–270. https://doi.org/10.2147/OAEM.S219333

www.emra.org/emresident/article/floaters-retinal-detachment-posterior-vitreous-detachment-or-vitreous-hemorrhage

A 44 year old female presents for anterior neck pain and chest pain. She first noticed neck pain yesterday. This morning the pain has radiated into her chest. Symptoms are worse with swallowing. Patient denies fever, sore throat, cough, shortness of breath, vomiting, or voice change, or difficulty eating/drinking. Chest x-ray is shown below. What’s the diagnosis?

Answer: pneumomediastinum (see separation of pericardium from heart border)

• May also present with physical exam finding of “Hamman’s crunch” on heart auscultation 
• Important to distinguish between primary (spontaneous/idiopathic) and secondary (traumatic, intrinsic lung disease, iatrogenic, and esophageal rupture)
  • Rule out secondary with advanced imaging modalities such as non-contrast CT chest and upper GI gastrograffin swallow study
• Treatment is supportive care
• Spontaneous pneumomediastinum may be discharged from ED with close outpatient follow up for repeat imaging

References:

Wang Y.L., & Jones D (2020). Pulmonary trauma. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Bakhos, C. T., Pupovac, S. S., Ata, A., Fantauzzi, J. P., & Fabian, T. (2014). Spontaneous pneumomediastinum: an extensive workup is not required. Journal of the American College of Surgeons, 219(4), 713–717. https://doi.org/10.1016/j.jamcollsurg.2014.06.001

Smith, B. A., & Ferguson, D. B. (1991). Disposition of spontaneous pneumomediastinum. The American journal of emergency medicine, 9(3), 256–259. https://doi.org/10.1016/0735-6757(91)90090-7