Retinal Detachment v Hemorrhage

By Dr. Raashee Kedia

Acute vision change

A 51 year old female with a history of diabetes presented to the ED with acute onset of left eye painless blurry vision. Vitals were within normal limits. Fingerstick was 450.

On exam : Visual acuity was 20/30 in the right eye but could only count fingers in left eye at 1 foot. There were no external signs of trauma, conjunctivitis or proptosis. Pupils were equal and reactive to light. Ocular ultrasound of her right and left eyes were performed and shown below:

R eye


IN the left eye a bright echogenic linear structure can be seen floating in the posterior aspect of the globe.  This was concerning for retinal detachment, which is a clear ocular emergency. Ophthalmology evaluated the patient in the emergency department and diagnosed a vitreous hemorrhage. The patient was discharged home.

How do you tell the difference between a vitreous hemorrhage and a retinal detachment?

First, a little anatomy of the eye:

Courtesy: National Eye Institute, National Institutes of Health (NEI/NIH).

The vitreous is a clear, gelatinous, and avascular substance, filling the space bound by the lens, retina, and optic disc. The retina is composed of multiple layers that form the posterior wall of the globe behind the vitreous. A retinal detachment occurs when these layers separate.

There is an internal membrane that separates the retina from the vitreous. This forms a potential space between the membrane and the vitreous called the subhyaloid space.

A vitreous hemorrhage occurs when blood extravasates into the vitreous or in the subhyaloid space. If bleeding has occurred in the subhyaloid space, it can appear boat-shaped on the surface of the retina, forming a superior straight line in an upright patient but changing with the position of the patient.

Ocular ultrasound is a quick and accessible way to assess ocular pathology. In patients with acute visual change, evaluation for retinal detachment is important to prevent complete and possibly permanent visual loss.

Ocular ultrasound is highly sensitive in the detection of retinal detachment in the ED.

With ocular ultrasound it can be difficult to distinguish between vitreous hemorrhage and retinal detachment. However, it is important to distinguish between these pathologies as they carry two different treatments and a different sense of urgency.

In an intact globe, the retina cannot be differentiated from the other choroidal layers on ultrasound.

Ultrasound of retinal detachment will show a thick hyperechoic membrane floating in the posterior globe. It never detaches from the optic nerve posteriorly.

Vitreous hemorrhage may layer and form a hyperdense linear density that can mimic a retinal detachment.

Decrease the gain to help differentiate between the two.

Vitreous hemorrhage is usually less dense and will fade as the gain is decreased. It usually layers inferiorly with gravity. Ocular movements produce a rapid, staccato motion of the hemorrhage, unlike a retinal detachment that is stiffer and slower in movements.


Schott, M, Pierog, J.,Williams, S. “Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss.” Journal of Emergency Medicine, Vol 44. Nov 2012.

Yanoff M, Duker JS. Opthalmology. 3rd ed. St Louis, MO: Mosby, An Imprint of Elsevier; 2008.

DiBernardo C, Greenberg E. Opthalmic ultrasound: A diagnostic atlas. 2nd ed. New York: Thieme MEidcal Publisers; 2007.

Second World Congress on Ultrasound in Medical Education

The University of South Carolina once again hosted the incredible World Congress on Ultrasound in Medical Education in Columbia. Dean Richard Hoppmann hosted over 100 faculty and hundreds of attendees, with dozens of countries represented.

Richard Hoppmann opening remarks

Mount Sinai emergency ultrasound director Bret Nelson gave a plenary talk on the use of ultrasound in remote environments, from the battlefield to the International Space Station.

Bet nelson Plenary talk WINFOCUS South Carolina

Pediatric emergency medicine ultrasound director Jim Tsung led a well-attended course on pediatric ultrasound, along with Ee Tay.

Jim Tsung-Teaching-Lung-USMount Sinai emergency ultrasound fellow Amy Sanghvi presented an abstract on a novel interdepartmental ultrasound education project. Obstetric and emergency medicine interns learned pelvic ultrasound through a combination of didactics, online tutorials, hands-on skill stations with live models and several types of simulators, then underwent an OSCE for competency assessment and completed an online interactive question bank.

Amy Sanghvi Abstract

There were far too many ultrasound visionaries to list them all here. Here we have Mike Mallin and Matt Dawson (of Ultrasound Podcast fame) and Vicki Noble (ultrasound director at MGH and thoracic ultrasound guru) making sure Bret’s seersucker was for real.

Mike Mallin, Bret elson, Vicki Noble, and Matt Dawson

Check out the World Congress website for the final program, images and videos from the conference, and more!

2013 Ultrasound Fellow Graduation

We were proud to graduate three ultrasound fellows this year:

  • Kim Poh Chan, our international fellow who will return to Singapore and head up a new ultrasound program
  • Daniel Lakoff, who will co-direct the ultrasound program at Elmhurst Hospital, and
  • Ee Tay, our first pediatric emergency ultrasound fellow, who will remain at Sinai
Left to right: Kim Poh Chan, Daniel Lakoff, Danny Duque, Bret Nelson, Amy Sanghvi, Ee Tay
Left to right: Kim Poh Chan, Daniel Lakoff, Danny Duque, Bret Nelson, Amy Sanghvi, Ee Tay

2013 Tri-State Ultrasound Fellow Conference

The first annual Tri-State Ultrasound Fellow Conference kicked off today at Lenox Hill Hospital in New York City. The first day of this two-day course focused on administrative issues in ultrasound, featuring nationally recognized speakers from all around the area.

Bret Nelson from the Icahn School of Medicine at Mount Sinai discussed faculty development, including:

  • Creating a niche
  • The educator portfolio
  • Making connections

Here are a few references from the talk:












Making Health Care Safer II


The AHRQ recently published an update to its landmark 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (AHRQ Evidence Report No. 43). This report advocated evidence-based practices such as root cause analysis, hand hygiene, ID bracelets for high risk patients, and time-outs prior to procedures.

The 2013 update analyzed 41 patient safety practices and identified 22 which were deemed ready for adoption. Ten were selected as “strongly encouraged” for adoption based on the strength and quality of evidence. Number nine on that list was “Use of real-time ultrasound for central line placement.

A special supplement to the March issue of Annals of Internal Medicine features articles related to many of these patient safety strategies, and is available for free online.

Looking through the top ten list, most interventions are implemented at most major hospitals, and JCAHO surveyors track adherence to guidelines such as these. Now that ultrasound use has made the top ten in two iterations of these AHRQ safety practices, it may be more difficult to argue that lack of availability or proper training absolves providers of the need to provide this service.

2013 St Luke’s Roosevelt Regional Ultrasound Symposium


2013 SLR Regional Symposium


This symposium is always worth the trip.  See you there.

Introduction to Bedside Ultrasound

Introduction to Bedside Ultrasound


It’s been out awhile now, but if you haven’t seen it yet, take a look at Mike and Matt’s Introduction to Bedside Ultrasound.  The ultrasound pocast guys have released this excellent overview of point of care ultrasound through the iTunes Store.  This is certainly convenient as most of us have 3-12 iDevices on our person at any one time.  Caveats are that this means that it is available only on an iPad using iBooks 2 or later, and ios 5 or later.  Right now it is $29.99.


There is a lot of good content, but I think the best chapter in the book, is probably the RUSH chapter. :)

  RUSH Exam