Catching Retinal Detachment in the ED: Split Vision

-Case-
A 62-year-old man presents to the ED complaining of sudden vision loss in his left eye. He describes it as a “curtain” coming down over his vision, with flashes of light and a shower of floaters. There’s no pain or redness, and he denies trauma. Visual acuity is decreased in the left eye. 

-Evaluation-
Retinal detachment is the separation of the neurosensory retina from the underlying retinal pigment epithelium. It’s a vision-threatening emergency that requires prompt ophthalmologic intervention.

  • Symptoms:
    • Sudden onset of painless vision loss
    • Flashes of light (photopsia)
    • New floaters
    • “Curtain” or “shadow” descending over vision
  • Risk Factors:
    • Age >50
    • Myopia (nearsightedness)
    • Recent cataract surgery
    • History of retinal detachment in the other eye
    • Trauma

Diagnosis:

  • Clinical History is often the most telling feature
  • Bedside ocular ultrasound:
    • Highly sensitive if performed correctly
    • Look for a hyperechoic, undulating membrane in the posterior chamber that moves with eye movement
  • Ophthalmology consultation:
    • All suspected cases need urgent evaluation
    • Dilated fundoscopic exam confirms diagnosis

-Management-

  1. Protect the Eye:
    • Minimize activity, patch the eye if instructed by ophthalmology
  2. Positioning:
    • Keep the head positioned so that the retina is maximally apposed (face down or lateral decubitus, depending on location)
  3. Ophthalmology Referral:
    • Emergent consult for retinal repair (e.g., laser photocoagulation, pneumatic retinopexy, vitrectomy)
  4. Avoid:
    • Topical drops unless directed
    • Pupil dilation unless coordinated with ophthalmology

-Fast Facts-

  • Ocular ultrasound can be a game-changer for early recognition
  • Time is vision – delays worsen prognosis!
  • Central vision spared early on if macula is not yet involved (mac-on detachment)
  • Requires emergent ophthalmologic follow-up

Sudden vision change with visual disturbances and no pain is textbook for this pathology. In the ED, rapid recognition and coordination with ophthalmology are key. A quick bedside ultrasound can make the diagnosis before the specialist even walks in. Because when the retina separates, the clock starts ticking on permanent vision loss.

Want to learn more? Listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

Accelerate your learning with our EM Question Bank Podcast

  • Rapid learning
  • Interactive questions and answers
  • new episodes every week
  • Become a valuable supporter
Sign up for the podcast

References:

  1. Ahmed A, Sadiq MA. Retinal Detachment. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024.
  2. Williamson TH. Retinal detachment. BMJ. 2016;353:i3806. doi:10.1136/bmj.i3806
  3. Storey PP, Obeid A, Khuthaila M, et al. Clinical outcomes and imaging characteristics of macula-on and macula-off retinal detachment repair. Ophthalmology. 2018;125(11):1631-1639. doi:10.1016/j.ophtha.2018.04.015
  4. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799. doi:10.1197/aemj.9.8.791
  5. Mitry D, Chalmers J, Anderson K, et al. Temporal trends in retinal detachment incidence in Scotland between 1987 and 2006. Br J Ophthalmol. 2011;95(3):365-369. doi:10.1136/bjo.2009.176990
Scroll to Top