The impact of ultrasound technique and timing on diagnosing vitreous hemorrhage: A case report

This case discusses the challenges and technical nuances of using point-of-care ultrasound (POCUS) to assist in the diagnosis of vitreous hemorrhage (VH) in the emergency department (ED) in a patient who presented to the ED with 2 h of painless blurry vision in their left eye that was preceded by one week of floaters. On initial POCUS, performed using a Tegaderm barrier placed directly atop the left eyelid, the eye was noted to have no evidence of retinal detachment (RD) or VH visible to the POCUS trained emergency medicine (EM) intern and faculty caring for the patient. During quality assurance review a day later, ultrasound fellowship trained EM faculty with the benefit of a darkened room and dedicated image review screen noted a barely visible diffuse echogenicity of the vitreous humor without the typical organized hyperechoic appearance of a VH. A second ultrasound the following day utilizing a dedicated on-probe ultrasound sheath rather than an on-eyelid Tegaderm™ barrier revealed a clear, organized, hyperechoic left vitreous hemorrhage with a possible RD. Ophthalmologic follow-up confirmed a VH with a small superonasal retinal tear. This case highlights the potential impact of ultrasound technique, settings, environment (including barrier selection), and time of presentation on image acquisition and diagnostic accuracy.