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A 69-Year-Old Female With Sudden Blurry Vision
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Visual Journal of Emergency Medicine 2C (2016) 55–56 www.elsevier.com/locate/visj
A 69-Year-Old Female With Sudden Blurry Vision Hyun-Chul D. Lee, MD, Viveta Lobo, MDn Emergency Medicine, Stanford University, 300 Pasteur Dr, M121 Alway Building, Stanford, CA
Keywords: lens dislocation; orbital ultrasound; point-of-care ultrasound; bedside ultrasound
Visual Case Discussion A 69-year-old female with a history of Marfan syndrome and a previously known subluxed left intraocular lens presented to the emergency department with a chief complaint of sudden blurry vision. Of note, the patient has been blind in the right eye for over 20 years. The day prior, the patient tilted her head back while brushing teeth and when she looked forward again, her vision had become completely blurry. On examination in the emergency department, the patient was unable to distinguish fingers although she could see vague shapes and light. Iridodonesis was present, but the retina could not be visualized by direct ophthalmoscopy. Point-of-care orbital ultrasound of the left eye revealed a posteriorly dislocated lens. Opthalmology was consulted emergently who urgently scheduled the patient for lensectomy (Fig.). Marfan syndrome is caused by an autosomal dominant mutation in the FBN1 gene, which encodes the extracellular matrix protein fibrillin 1. Ectopia lentis occurs in 50–80% of patients with Marfan syndrome, and encompasses both lens subluxation (partial dislocation of the lens) and luxation (complete dislocation). Management of ectopia lentis is typically non-surgical with a goal of optimizing optical refraction. However, surgical options are considered when conservative measures fail, or when complete luxation occurs. Point-of-care ultrasound can easily and rapidly diagnose lens dislocation. A high frequency linear transducer is used, and gently placed over the closed eye using a generous amount of water soluble ultrasound gel. Normally, the hypoechoic fluid filled globe is visualized, with the anterior chamber and the disc shaped lens located anteriorly. In our image, the lens is clearly displaced from its normal anterior position, and is seen posteriorly. In addition, orbital ultrasound can quickly evaluate for potential alternative diagnoses such as vitreous hemorrhage and retinal detachment.
n
Corresponding author. E-mail address: [email protected] (V. Lobo).
http://dx.doi.org/10.1016/j.visj.2015.09.004 2405-4690/Published by Elsevier Inc.
56
H.-C.D. Lee, V. Lobo / Visual Journal of Emergency Medicine 2C (2016) 55–56
Fig. Left Ocular Ultrasound with dislocated lens.
Appendix. Supplementary Materials Supplementary material cited in this article is available online at http://dx.doi.org/10.1016/j.visj.2015.09.004.
References [1] Boniface, Keith S, Ahmad Aalam, Mohammad Salimian, Yiju Teresa Liu, Hamid Shokoohi. Trauma-induced bilateral ectopia lentis diagnosed with point-of-care ultrasound. J Emerg Med 2015;48(6):e135–e137. http://dx.doi.org/10.1016/j.jemermed.2015.01.004. [2] Miraldi Utz, Virginia, Razek Georges Coussa, Traboulsi Elias I. Surgical management of lens subluxation in Marfan syndrome. J Am Assoc Pediatr Ophthalmol Strabismus 2014;18(2):140–146. http://dx.doi.org/10.1016/j.jaapos.2013.12.007. [3] Shinar, Zachary, Linda Chan, Michael Orlinsky. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med 2011;40(1): 53–57. http://dx.doi.org/10.1016/j.jemermed.2009.06.001.
Available online at www.sciencedirect.com
Visual Journal of Emergency Medicine 2C (2016) 55–56 www.elsevier.com/locate/visj
A 69-Year-Old Female With Sudden Blurry Vision Hyun-Chul D. Lee, MD, Viveta Lobo, MDn Emergency Medicine, Stanford University, 300 Pasteur Dr, M121 Alway Building, Stanford, CA
Keywords: lens dislocation; orbital ultrasound; point-of-care ultrasound; bedside ultrasound
Visual Case Discussion A 69-year-old female with a history of Marfan syndrome and a previously known subluxed left intraocular lens presented to the emergency department with a chief complaint of sudden blurry vision. Of note, the patient has been blind in the right eye for over 20 years. The day prior, the patient tilted her head back while brushing teeth and when she looked forward again, her vision had become completely blurry. On examination in the emergency department, the patient was unable to distinguish fingers although she could see vague shapes and light. Iridodonesis was present, but the retina could not be visualized by direct ophthalmoscopy. Point-of-care orbital ultrasound of the left eye revealed a posteriorly dislocated lens. Opthalmology was consulted emergently who urgently scheduled the patient for lensectomy (Fig.). Marfan syndrome is caused by an autosomal dominant mutation in the FBN1 gene, which encodes the extracellular matrix protein fibrillin 1. Ectopia lentis occurs in 50–80% of patients with Marfan syndrome, and encompasses both lens subluxation (partial dislocation of the lens) and luxation (complete dislocation). Management of ectopia lentis is typically non-surgical with a goal of optimizing optical refraction. However, surgical options are considered when conservative measures fail, or when complete luxation occurs. Point-of-care ultrasound can easily and rapidly diagnose lens dislocation. A high frequency linear transducer is used, and gently placed over the closed eye using a generous amount of water soluble ultrasound gel. Normally, the hypoechoic fluid filled globe is visualized, with the anterior chamber and the disc shaped lens located anteriorly. In our image, the lens is clearly displaced from its normal anterior position, and is seen posteriorly. In addition, orbital ultrasound can quickly evaluate for potential alternative diagnoses such as vitreous hemorrhage and retinal detachment.
n
Corresponding author. E-mail address: [email protected] (V. Lobo).
http://dx.doi.org/10.1016/j.visj.2015.09.004 2405-4690/Published by Elsevier Inc.
56
H.-C.D. Lee, V. Lobo / Visual Journal of Emergency Medicine 2C (2016) 55–56
Fig. Left Ocular Ultrasound with dislocated lens.
Appendix. Supplementary Materials Supplementary material cited in this article is available online at http://dx.doi.org/10.1016/j.visj.2015.09.004.
References [1] Boniface, Keith S, Ahmad Aalam, Mohammad Salimian, Yiju Teresa Liu, Hamid Shokoohi. Trauma-induced bilateral ectopia lentis diagnosed with point-of-care ultrasound. J Emerg Med 2015;48(6):e135–e137. http://dx.doi.org/10.1016/j.jemermed.2015.01.004. [2] Miraldi Utz, Virginia, Razek Georges Coussa, Traboulsi Elias I. Surgical management of lens subluxation in Marfan syndrome. J Am Assoc Pediatr Ophthalmol Strabismus 2014;18(2):140–146. http://dx.doi.org/10.1016/j.jaapos.2013.12.007. [3] Shinar, Zachary, Linda Chan, Michael Orlinsky. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med 2011;40(1): 53–57. http://dx.doi.org/10.1016/j.jemermed.2009.06.001.