Case 1

1. There is a 30% pneumothroax in the left chest. In the right chest, there is a cavitary lesion in the upper lobe there with a significant amount of associated volume loss.

2. The patient has active tuberculosis with a loculated PTX. In contrast to a primary PTX, this is a secondary PTX because it arises secondary to the underlying lung disease. These are usually seen in patients with COPD due to a ruptured bleb. All patients with a secondary spontaneous PTX should be initially hospitalized because they have decreased pulmonary reserve and can develop associated serious complications. For PTX large enough to require decompression, treatment with a chest tube has better success than needle thoracostomy.

Pearls:
1. Secondary spontaneous PTX is usually associated with underlying COPD, but can occur with nearly every underlying lung disease
2. The majority of patients with secondary spontaneous PTX require admission for continued monitoring

Case 2

1. On the ultrasound of the right eye, there is an abnormal hyperechoic stripe originating from the posterior wall that is floating in the anechoic, darker appearing fluid of the vitreous cavity.

2. The diagnosis is a retinal tear with retinal detachment of the right eye. Retinal detachment occurs in approximately 1% of patients in the weeks to years following cataract surgery. New onset floaters, associated with flashing lights indicate a retinal tear, while visual field defects are a late symptom of retinal detachment.

Treatment is generally surgical, and therefore these patients should be emergently referred to an ophthalmologist for definitive treatment. Time is critical, and the prognosis is in part related to how long the retina has been detached as well as the extent of involvement of the central macula.

3. For the emergency physician performing ocular ultrasound at the bedside, the goal is to determine if there is increased ICP that correlates with an optic nerve sheath diameter greater than 5mm. Also, the bedside ocular ultrasound can show pathology such as lens dislocation, retinal detachment and foreign body. The anterior segment of the eye consists of the cornea, the iris, pupil, lens and anterior chamber. The posterior chamber consists of the vitreous humor, choroid, retina and optic nerve.

On ultrasound, fluid is black or anechoic while solid structures are lighter or hyperechoic. The anterior chamber is seen on ultrasound as a dark structure separated by hyperechoic lines of the lens from the dark posterior chamber. The optic nerve is a dark band-like structure that starts at the optic disk. The retina is not seen as a separate entity unless it is detached.


Pearls:
1. Previous cataract surgery is a significant risk factor for retinal detachment.
2. On ultrasound, the retina will not appear as a separate entity unless it is detached.
3. Retinal detachment is a time sensitive diagnosis, with emergent ophthalmologic referral necessary.