Doctor Explains Retinal Detachment

Added: 2026-05-09

[00:00:00]If I had a nickel for every time my ED tried to admit a code stroke patient with an NIHSS of two for visual field deficits that upon my exam were actually found to be monocular vision loss and subsequently demonstrated complete retinal detachment on ocular point-of-care ultrasound prompting an emergent ophthalmology consult and transfer to a hospital with eye surgery capabilities for scleral buckling, I would have two nickels. Which isn't a lot, but it's weird that it's happened twice. But yeah, I had a case of retinal detachment the other day. Well, not me, but a a patient that I, you know, was supposed to admit to the hospital had it. It is definitely not an everyday diagnosis I encounter as an internal medicine doctor seeing a patient in the ED, but it definitely highlights the importance of taking a good history and having the proper exam skills and not just taking the emergency team's evaluation for granted. This was actually the second time I had a patient like this with a story that was eerily similar to the first one that I encountered in residency. Even down to the workup done in the ED, it was getting pretty close. This was really one of those cases where if I hadn't had the exact same presentation and sequence of events that one time back in my intern year, I might have missed this diagnosis entirely. I could have admitted the patient as a stroke workup per the teleneurologist evaluation and the emergency doc and wasted critical hours in getting them the ophthalmological help that they really needed. So, retinal detachment in itself is not too common of a diagnosis and usually happens spontaneously either in cases of facial trauma or in the elderly. It can also happen as a consequence of late-stage diabetic retinopathy or in a patients with Marfan's, which is a genetic connective tissue disorder. Due to its namesake pathology, the retina will pop off the retinal pigment epithelium causing monocular vision loss. But sometimes this can be unclear for the patient to describe or the provider to evaluate prompting a stroke workup for a neurological issue instead of a physical eyeball issue. Retinal detachment isn't going to show up on a CT or MRI as part of a stroke workup. So, if you're not an eye doctor or an expert with the ophthalmoscope, the absolute quickest way to see if retinal detachment is the problem or not is to do an ocular ultrasound. Like seriously, just slap a Tegaderm on the patient's eye, squeeze the gel, and just start using the probe.

[00:02:17]Basically, you get the patient to look around and try to blink behind their eyeball. And if the retina is detached, you can clearly see the floating layer bouncing around. It is actually extremely easy and quick to perform, and I think more people should be familiar with doing this on ultrasound, since you can really save someone's eyesight with a 2-minute exam. For the case that I had with the patient my intern year, I actually got their permission to write it up as a case report, and even presented it at the Society for Hospital Medicine meeting in 2023. Just look at the retina on the right eye, just flopping all around like That That's not supposed to do that.

[00:02:51]It's important to remember that retinal detachment is a surgical emergency. So, early diagnosis by the provider is key.

[00:02:58]And unless you're presenting to an ED that's stocked with an ophthalmologist on call, which is neither of the hospitals where I had these patients, that means it's going to be on the EM and IM providers to get it right.

[00:03:08]Ultimately, for both of these cases, I caught them both in the emergency department and could initiate early transfer to a hospital for surgery for scleral buckling. This one is an ophthalmologic surgery where they basically just wrap a band around the eye to squeeze the retina back into place. There's also another procedure for superior retinal detachments called pneumatic retinopexy, where they inject sulfur hexafluoride or perfluoropropane gas straight into the vitreous body, and the pressure differential just seals the retina back up against the epithelium, and that's kind of gnarly.

[00:03:39]Shoutout to Sharkbait for having gone through two retinal detachments before and sharing that with us. Anyway, in conclusion, retinal detachment is not a very common diagnosis for the hospital doctor, but just underlines the importance of proper physical exams, knowing what quick tests you can do to confirm your suspicions, and not just taking an ED sign out for granted.

[00:04:00]Waiting to follow through with a stroke workup or for the MRI to come back negative to prompt an eyeball investigation may have been too late to save this patient's eyesight. And, in case you were wondering, this patient also got scleral buckling surgery and made a full recovery by the next day.