SonoCase: 2 yr old walking into things, now cups his eye to focus…. What’s up with that eye?!

Very cool pick-up we had recently, the early diagnosis allowed better outcome, and I’ve only seen this twice before by bedside US in the ED. It was an unusually calm Monday in the pediatric ER, lots of coughs and colds, and more hand-foot-mouth disease than ever recorded in history, Im sure. Then we saw this very cute 2 year old boy walk into the ER wearing a “Poop happens” T-shirt, with his hand covering his left eye while walking to the room, then hopping on the gurney and immediately taken by the iPAD we have for kids to play games on…. According to the parents, over the last several weeks, he started walking into things. His father laughed when describing that when he would try to follow his older brother run down the hallway, he would get clocked in the shoulder by the edge of the hallway entrance. He saw his pediatrician who noticed a slight cross-eye appearance, got general lab tests that were normal and said to return in one week for a recheck and ophtho referral. Well, in that week he started cupping his eye, and when he does that – problem solved! His pupils were equal and reactive, extraocular movements normal, did appear slightly crossed eyed – all other exam sections normal. I skipped my exam with the ophthalmoscope because Ive always sucked at it anyway – and ever since bedside US started to be appreciated with ocular studies, I go directly to that for screening for the big stuff: retinal detachment, vitreous hemorrhage, papilledema, orbital trauma evaluation (lens dislocation, orbital rupture, retrobulbar hematoma).

So, I place a tegaderm over the eye (for easy removal of gel after the exam – kids like that), apply lots of gel on the linear transducer and place it on the tegaderm over the closed eyelid  – with the indicator toward the patients right side then cephalad while fanning through the eyeball in each view.  The cute kid was moving a bit but I could see the problem – When we walked out of the room, the resident asked, “What’s up with that eye?!”:

Called ophtho and peds: “By ultrasound there is an irregular;y bordered and immobile mass with varying echoes attached to the retina which is concerning for retinoblastoma.”  – admitted for possible chemo-radiation…..