Trick of the Trade: Ocular ultrasound for the swollen traumatic eye

You are caring for a patient with an incredibly swollen eye – like a scene out of almost any Rocky film. This patient is likely going to the CT scanner, but regardless of the finding (retrobulbar hematoma, orbital wall fracture, etc.) you still need to evaluate for extraocular muscle entrapment and loss of pupillary response. There’s only one problem: you can’t see the eye. The old standards like getting the patient to retract their lid using paperclips or a cotton swab may help, but sometimes there is just too much swelling, and those techniques are just not enough. Without brute force – and potentially causing more trauma – you likely won’t be able to examine this patient’s eye.

Trick of the Trade:

Use your ultrasound to visualize both pupillary response and eye movements

Some of the first applications of ultrasound in medicine were for ocular evaluation, such as for retinal detachment, hemorrhage or papilledema [1-3]. However, you can also use some of these skills to evaluate the function of the optic nerve and extraocular muscles.

“I would argue that you can use ultrasound to get all of the information you need to evaluate the eye after a traumatic injury.” – Dr. Nate Teismann, Director of Emergency Ultrasound (UCSF)

Technique

1. Apply sterile lubricating jelly over the swollen eyelid.
2. With minimal pressure, gently place the linear probe of your ultrasound over the affected eye.

1. Extraocular muscle movement:
   • If your patient is awake, place the ultrasound probe in the axial plane and request to look left and right.
   • Then place the probe in the sagittal plane, and ask the patient to look up and down.
   • Watch for the associated movement as the globe rotates on the screen.  If you don’t see symmetric globe movement in a particular direction, you may have an entrapped extraocular muscle.

2. Pupillary response: [previous post on this trick]
   • Place the linear ultrasound probe inferior to the eye, angling superiorly towards the patient’s head, or place the probe superior to the eye angling toward the feet depending on the swelling.
   • Locate the optic nerve, lens, and iris.
   • Shine a light in the affected or non-affected eye (for consensual light reflex), and look for papillary constriction and reactivity of the iris.

Being able to complete these primary evaluations of the eye without additional pressure or trauma to the affected eye may quickly affect management and save time in a busy ED.

References

1. Harries A, Shah S, Teismann N, Price D, Nagdev A. Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma. Am J Emerg Med. 2010;27(1), 956–959. PMID 20887915 
2. Teismann N, Lenaghan P, Nolan R, Stein J, Green A. Point-of-care ocular ultrasound to detect optic disc swelling. Acad Emerg Med. 2013;20(9), 920–925. PMID 24050798
3. Howard Z, Gharahbaghian L. Emergency Ultrasound Tips and Tricks. American College of Emergency Physicians.

Author information

Christian Rose, MD

Clinical Informatics Fellow
Stanford University;
Emergency Physician, Kaiser Permanente

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