SonoCase: 82yr old prior orbital trauma, now with eyelid swelling and pain

This case was quite interesting and a great pick-up by the EM resident, Dr Cesar Avila. It highlights the use of ocular ultrasound with eye complaints/vision change/trauma, especially when you cannot properly evaluate the eye well due to eyelid swelling.

82 year old male with history of globe rupture and retinal detachment status post repair two months earlier presents to the ED with eyelid swelling of that same eye, gradual onset over one day with now inability to open eyelids well with yellow discharge coming from eye. No fever, stable vitals, mild achy eye pain diffusely especially when moving eye, upper and lower eyelid warmth and redness, and poor ocular exam due to eyelid swelling and prior history – making it difficult to know what’s normal and what’s not, structurally speaking, on this day. The swelling, redness, and discharge is new and the concern was for orbital or periorbital cellulitis. Dr. Avila placed the linear ultrasound probe over the closed eye using lots of gel and saw the below images:

So, it was obvious that the usually normal circular orbit didn’t exist anymore – it was more oval – and the anterior and posterior chambers weren’t well demarcated, and we cannot see a lens – but this could be from the prior globe rupture and repair – hard to say. But, one thing was obvious: this day’s problem wasn’t just an external/eyelid problem, as there was an abnormal echogenicity within the orbit – it’s supposed to be anechoic/black – this upgrades the diagnosis to endophthalmitis, once correlating clinically to the exam. Vitreous hemorrhage can look the same way, but hemorrhage usually floats in the fluid of the eye and is more mobile with eye movement. Given how the patient presented, and how that echogenicity seems stuck to the posterior of the eye, vitreous hemorrhage was lower on the differential, and pus was higher up. Ophtho was called, IV antibiotics ordered, CT orbits (as requested by ophtho) confirmed the diagnosis, the patient was admitted, and an ocular tap was done showing pus…recovered well, relatively speaking, of course.

In order to compare the above with what a normal ocular US looks like, see below for a normal orbit:

For a trick on how to “See” the orbit better, see my prior post.