Long-term visual outcome in Terson syndrome

Outcome of vitrectomy in patients with Terson syndrome

PURPOSE

To report findings and evaluate the results of vitrectomy in 22 eyes with Terson syndrome.

METHODS

We reviewed retrospectively the records of patients who underwent pars plana vitrectomy as a result of vitreous haemorrhage. Twelve cases concerned unilateral vitrectomy and five concerned bilateral vitrectomy. The time interval between intracranial haemorrhage and vitrectomy was 1-10 months (mean 5.9 months).

RESULTS

During a mean follow-up of 23.3 months (range 1-69 months) visual acuity (VA) improved in 21 of 22 eyes. Preoperative VA was < or = 0.1 in 20 of 22 eyes, while postoperative VA was > or = 0.5 in 16 of 21 eyes. Poor visual outcomes were mainly caused by retinal detachments (seven eyes, in which three were caused by proliferative vitreoretinopathy), epiretinal membranes (seven eyes) and optic atrophy (one eye). Our study concurs with recent reports suggesting early vitrectomy in bilateral cases and in cases where ultrasonography shows epiretinal membrane or proliferative retinopathy formation.

Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure

Object

The syndrome of retinal or vitreous hemorrhage in association with subarachnoid hemorrhage (SAH) is known as Terson's syndrome. The authors' purpose was to determine whether intraocular hemorrhage occurs with similar incidence when caused by severe brain injury accompanied by acutely raised intracranial pressure (ICP).

Methods

Prospective ophthalmological examination was performed in 22 consecutive patients with SAH or severe brain injury and elevated ICP. Thirteen patients were admitted for SAH (World Federation of Neurological Surgeons Grades II–IV) and nine for severe brain injury (Glasgow Coma Scale scores 3–10). Monitoring of ICP was performed at the time of admission via a ventricular catheter. Initial ICP exceeded 20 mm Hg in all patients. Indirect ophthalmoscopy without induced mydriasis was performed within the 1st week after the acute event. Retinal or vitreous hemorrhage was seen in six (46%) of 13 patients with SAH and in four (44%) of nine patients with severe brain injury. Ocular bleeding was found bilaterally in three patients with SAH and in one patient with severe brain injury (18%). Six of the 10 patients with Terson's syndrome died as a result of their acute event.

Conclusions

The present results indicate that Terson's syndrome may be related to acute elevation of ICP, independent of its causes, and may occur with similar incidence in patients with severe brain injury and those with SAH. Because recognition and treatment of Terson's syndrome may prevent visual impairment and associated secondary damage to the eye, increased awareness of this entity in all patients with acute raised intracranial hypertension is recommended.

Terson syndrome: a case report suggesting the mechanism of vitreous hemorrhage

OBJECTIVE

To present a patient with Terson syndrome and to propose a mechanism for vitreous hemorrhage.

DESIGN

Observational case report.

PARTICIPANT

A 50-year-old woman with subarachnoid hemorrhage and unilateral vitreous hemorrhage.

METHODS

Detailed examination with fluorescein angiography and funduscopy.

MAIN OUTCOME MEASURES

Site of dye leakage on fluorescein angiography in the eye with vitreous hemorrhage.

RESULTS

Fluorescein angiography showed the leakage site at the margin of the disc in the eye with vitreous hemorrhage after the vitreous hemorrhage had been removed.

CONCLUSIONS

The damage to peripapillary tissues demonstrated by fluorescein leakage suggests that intracranial hypertension affects peripapillary structures through the intervaginal space of the optic nerve sheath.

Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome

PURPOSE

To report the surgical technique, outcome, and histologic findings involving indocyanine green staining and removal of internal limiting membrane in primary macular hole surgery.

METHODS

Prospectively, consecutive patients with idiopathic macular hole or myopic macular hole with retinal detachment were recruited. After pars plana vitrectomy and epiretinal membrane removal, the internal limiting membrane was stained and removed. The specimens were stained using hematoxylin and eosin and periodic acid-Schiff. Immunohistochemical staining was also performed for glial fibrillary acidic protein, vimentin, type I and type IV collagen, and actin.

RESULTS

Among 10 patients (10 eyes) in the study, nine eyes had stage 3 or 4 macular hole. Four of them had chronic macular hole. The tenth patient had retinal detachment resulting from a myopic macular hole. Postoperatively, all cases had closure of macular hole without an elevated edge and the retina was attached. Seven patients had improvement of 2 or more Snellen lines, whereas visual acuity remained the same for the other three patients. In six eyes in which complete histologic examinations were feasible, internal limiting membrane was confirmed and two eyes also had a small amount of epiretinal membrane. Myofibrocytes in internal limiting membrane, either scattered or as a single layer, were found in three cases.

CONCLUSIONS

Removal of indocyanine green--stained internal limiting membrane around idiopathic macular hole or myopic macular hole with retinal detachment is confirmed with histology and may contribute to macular hole closure and retinal reattachment.

When does low mean high? Isolated cerebral ventricular increased intracranial pressure in a patient with a Chiari I malformation

OBJECTIVE

To present an unusual case of pseudotumor cerebri with increased intracranial pressure isolated to the cerebral ventricles resulting from a Chiari I malformation.

MATERIALS AND METHODS

The patient received a complete ophthalmologic examination on initial presentation and subsequent visits, including visual acuity, pupillary examination, intraocular pressures, dilated fundus examination with assessment of degree of papilledema, and visual field testing. Intracranial pressure was measured by lumbar puncture and subsequently by intracranial pressure bolt monitoring. Magnetic resonance imaging (MRI) was used to diagnose the Chiari I malformation.

RESULTS

The patient initially presented with bitemporal headaches, elevated opening pressure on lumbar puncture, and mild papilledema with a normal MRI. After lumboperitoneal shunt placement and several revisions, the patient presented with decreased vision OD secondary to Terson syndrome and worsening papilledema. Subsequent evaluation revealed normal lumbar opening pressures and a Chiari I malformation. She underwent ventriculoperitoneal shunt placement with resolution of her symptoms.

CONCLUSIONS

Tonsillar herniation is a well-documented complication of lumboperitoneal shunt revision. Obstruction of cerebrospinal flow through the foramina of Magendie and Luschka can result in increased intracranial pressure isolated to the cerebral ventricles. In a patient with signs and symptoms of increased intracranial pressure but normal lumbar opening pressure, a Chiari I malformation should be suspected, particularly with a history of multiple lumboperitoneal shunt revisions.

Surgical approach in terson syndrome: vitreous and retinal findings

PURPOSE

To report some interesting findings in patients with bilateral Terson syndrome.

METHODS

We describe six eyes from three patients with Terson syndrome. Pars plana vitrectomy was performed in one eye twelve weeks, and in four eyes six months after the acute event. In one eye blood was suddenly spontaneously absorbed after four months.

RESULTS

The four eyes operated six months after injury showed severe complications and final visual acuity was between light perception and 0.6. The eye with surgical attendance twelve weeks after the acute injury had an uneventful course, and final visual acuity was 0.7.

CONCLUSIONS

Because of severe ocular complications and with a view to early rehabilitation, vitrectomy has been recommended for eyes with bilateral Terson syndrome, without spontaneous blood resorption. Surgery should be performed in at least one eye not later than four to eight weeks after the acute injury.

Terson syndrome caused by ventricular hemorrhage associated with moyamoya disease--case report

A 24-year-old female presented with Terson syndrome secondary to bilateral ventricular hemorrhage as a complication of moyamoya disease. Ophthalmoscopy and magnetic resonance imaging clearly demonstrated vitreous hemorrhage in the left eye globe. Various visual symptoms are associated with moyamoya disease, almost all of which result from ischemic lesions in the visual cortex and optic pathways. In this case, the visual disturbance was caused by Terson syndrome secondary to ventricular hemorrhage. Close ophthalmological and radiological evaluation is mandatory even in patients with moyamoya disease and hemorrhagic manifestation located in the intracerebral, subarachnoid, or intraventricular space.

Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure

OBJECT

The syndrome of retinal or vitreous hemorrhage in association with subarachnoid hemorrhage (SAH) is known as Terson's syndrome. The authors' purpose was to determine whether intraocular hemorrhage occurs with similar incidence when caused by severe brain injury accompanied by acutely raised intracranial pressure (ICP).

METHODS

Prospective ophthalmological examination was performed in 22 consecutive patients with SAH or severe brain injury and elevated ICP. Thirteen patients were admitted for SAH (World Federation of Neurological Surgeons Grades II-IV) and nine for severe brain injury (Glasgow Coma Scale scores 3-10). Monitoring of ICP was performed at the time of admission via a ventricular catheter. Initial ICP exceeded 20 mm Hg in all patients. Indirect ophthalmoscopy without induced mydriasis was performed within the 1st week after the acute event. Retinal or vitreous hemorrhage was seen in six (46%) of 13 patients with SAH and in four (44%) of nine patients with severe brain injury. Ocular bleeding was found bilaterally in three patients with SAH and in one patient with severe brain injury (18%). Six of the 10 patients with Terson's syndrome died as a result of their acute event.

CONCLUSIONS

The present results indicate that Terson's syndrome may be related to acute elevation of ICP, independent of its causes, and may occur with similar incidence in patients with severe brain injury and those with SAH. Because recognition and treatment of Terson's syndrome may prevent visual impairment and associated secondary damage to the eye, increased awareness of this entity in all patients with acute raised intracranial hypertension is recommended.

The ophthalmology of intracranial vascular abnormalities

PURPOSE

To provide a practical review of the ophthalmologic manifestations of intracranial vascular abnormalities.

METHODS

We reviewed ocular manifestations of the most common intracranial vascular abnormalities: intracranial aneurysms, carotid-cavernous fistulas, arteriovenous malformations, and cavernous malformations.

RESULTS

Unruptured aneurysms can compress the third cranial nerve and the anterior visual pathways. Ruptured aneurysms and subarachnoid hemorrhage can result in Terson syndrome and papilledema. Direct and indirect carotid-cavernous fistulas most commonly cause the classic triad of proptosis, conjunctival chemosis, and cranial bruit but can masquerade as chronic conjunctivitis. Arteriovenous malformations, with or without hemorrhage, may compress portions of the retrochiasmal pathways, causing visual field loss. Cavernous malformations, when in the brainstem, commonly cause abnormalities of supranuclear, nuclear, and fascicular ocular motility.

CONCLUSIONS

The ophthalmologist may be the first physician to encounter clinical manifestations of intracranial vascular abnormalities that may herald devastating neurologic complications. Prompt diagnosis facilitates appropriate management and therapy.

Terson syndrome. Results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid hemorrhage

OBJECTIVE

The purpose of study A was to assess the effectiveness of vitrectomy for Terson syndrome. The purpose of study B was to determine the incidence and significance of vitreous hemorrhage in patients with subarachnoid hemorrhage.

DESIGN

Study A is a retrospective review of case series. Study B is a prospective study.

PARTICIPANTS

Study A examined a consecutive series of 4 children (7 eyes) and 23 adults (26 eyes). Study B examined a consecutive series of 100 patients.

INTERVENTION

Subjects in study A underwent pars plana vitrectomy for dense vitreous hemorrhage following intracranial hemorrhage. In study B, ophthalmoscopic examination of patients undergoing neurosurgery for ruptured cerebral aneurysms was used.

MAIN OUTCOME MEASURES

In study A, the extent and rapidity of visual recovery and intraoperative and postoperative complications were examined. In study B, the incidences of intraocular hemorrhage and Terson syndrome in the cohort and the significance of the presence of vitreous hemorrhage in patients with subarachnoid hemorrhage were examined.

RESULTS

Study A: There was substantial and rapid visual improvement in 25 of the 26 eyes (96%) of the adult patients, with 21 eyes (81%) achieving > or = 20/30 final visual acuity. Only limited improvement was achieved in children's eyes (< or = 20/60). Study B: Intraocular hemorrhage was found in 17% of eyes in patients with subarachnoid hemorrhage; the incidence of Terson syndrome was 8%. All patients with Terson syndrome and 89% of the patients with other types of intraocular hemorrhage had a history of coma compared with 46% of those without intraocular hemorrhage (P = 0.0003).

CONCLUSIONS

Vitreous hemorrhage in patients surviving subarachnoid hemorrhage appears to be more common than previously thought, underscoring the need for routine funduscopic screening. Surgical intervention is highly effective in hastening visual rehabilitation of adults with Terson syndrome. The less encouraging results in infants may be due to amblyopia or direct brain damage caused by the cerebrovascular incident.

Terson's syndrome. Report of a case with favorable outcome

Terson's syndrome is characterized by the presence of a subarachnoid hemorrhage accompanied by retinal and vitreous hemorrhage leading to a not very favorable prognosis. We describe a case with a good outcome, probably because of a early diagnosis and medical intervention. We emphasize the routine optician's check up as very important in the evaluation of a prognosis in the cases of a suspect intracranial hemorrhage.

Bilateral subinternal limiting membrane hemorrhage with Terson syndrome

PURPOSE

To report the anatomic location of bilateral dome-shaped posterior pole hemorrhages in a patient with Terson syndrome.

METHODS

Case report. We performed bilateral vitrectomy for vitreous hemorrhage in a patient with Terson syndrome. After removal of vitreous hemorrhage, the tissue overlying a large discrete hemorrhage in the posterior pole was removed, and the tissue from one eye was examined histologically.

RESULT

The discrete dome-shaped hemorrhage in the posterior pole was confined to the retina anteriorly by the internal limiting membrane.

CONCLUSION

Large dome-shaped retinal hemorrhages with Terson syndrome can be located beneath the internal limiting membrane of the retina.

Vitreous Hemorrhage

The incidence of spontaneous vitreous hemorrhage is approximately 7 cases per 100,000 population. Proliferative diabetic retinopathy (32%), retinal tear (30%), proliferative retinopathy after retinal vein occlusion (11%) and posterior vitreous detachment without retinal tear (8%) are the most common causes of spontaneous vitreous hemorrhage. Vitreous hemorrhage can be caused by the pathologic mechanisms of disruption of normal retinal vessels, bleeding from diseased retinal vessels or abnormal new vessels, and extension of hemorrhage through the retina from other sources. Hemorrhage into the vitreous gel results in rapid clot formation and is followed by slow clearance of approximately 1% per day. The cellular response to vitreous hemorrhage is unusual with regard to hemorrhage in any tissue outside the vitreous cavity and has been compared to a "low-turnover" granuloma. Unique clinicopathologic features of long-standing vitreous hemorrhage include cholesterolosis bulbi (synchysis scintillans), hemoglobin spherulosis, and vitreous cylinders. Complications of nonclearing vitreous hemorrhage are hemosiderosis bulbi and glaucoma. Ghost cell glaucoma, hemolytic glaucoma, and hemosiderotic glaucoma may result from vitreous hemorrhage. The established treatment option for nonclearing vitreous hemorrhage is pars plana vitrectomy. Experimental nonsurgical treatment options involve improvement of physiologic clearance mechanisms in order to accelerate fibrinolysis, liquefaction, hemolysis and phagocytosis.

Dense vitreous hemorrhages predict poor visual and neurological prognosis in infants with shaken baby syndrome

OBJECTIVE

A retrospective study was performed to examine the relationship between the severity of vitreous hemorrhages and the severity of neurological injury in infants with shaken baby syndrome, and the result of early vitrectomy in these infants.

METHODS

Five infants, ages 3 to 8 months, with confirmed child abuse underwent ocular examination and neurological testing to identify varying degrees of vitreoretinal changes and neurological dysfunction. Pars plana vitrectomy was performed on one or both eyes in each infant to remove the vitreous hemorrhage.

RESULTS

The three infants with bilateral dense vitreous hemorrhage and multiple subarachnoid hemorrhage and cerebral contusions had poor postoperative ocular and neurological outcomes including light perception (LP) or no light perception (NLP) vision, large retinal holes or tears, retinal ischemia, and severe encephalopathy. The other two infants presented with bilateral subhyaloid and retinal hemorrhages without dense vitreous involvement, along with mild subarachnoid hemorrhage and minimal neurological findings. Following vitrectomy, visual acuities in these infants improved to or remained at the fix and follow state, and both infants improved neurologically.

CONCLUSIONS

The presence of dense vitreous hemorrhage in infants with shaken baby syndrome has a poor visual prognosis, due to the frequent concomitant occurrence of significant retinal and visual cortical pathology. In contrast, infants with only intraretinal or subhyaloid hemorrhage tend to have a much better prognosis, with less disruption of both intraocular and intracranial structures.

Vitreous findings in a patient with Terson's syndrome

In Terson's syndrome a sudden increase in intracranial pressure due to spontaneous subarachnoid hemorrhage or head trauma may result in intraocular hemorrhage. A patient with bilateral vitreous hemorrhages underwent vitrectomy in both eyes with excellent result. In the right eye a glistening membrane was found with blood underneath, covering the macula. This was probably the internal limiting membrane (ILM). At the vitreous base and in the equatorial zone, attachment plaques are present between the ILM and the Müller cells. Because attachment plaques are missing in the posterior zone, where the ILM is much thicker, a retinal hemorrhage is capable of detaching the ILM from the retina in that area. The presence of attachment plaques is considered in relation to centripetal vitreous traction, which is absent in the area of the posterior precortical vitreous pocket (PPVP). The posterior wall of the PPVP coincides therefore probably exactly with the thick part of the ILM in the posterior zone.

Retinal detachment with severe proliferative vitreoretinopathy in Terson syndrome

BACKGROUND

In several reports, early vitrectomy has been proposed for eyes with vitreous hemorrhage due to Terson syndrome as a means to hasten visual recovery. But the development of nuclear sclerosis and the neurologic problems arising from this disease encourage surgeons to wait for spontaneous resorption, especially with young patients. Although the formation of epiretinal membranes has been described, to the authors' knowledge retinal detachment with proliferative vitreoretinopathy in Terson syndrome never has been observed.

METHODS

The authors report five eyes from four patients with Terson syndrome due to spontaneous aneurysm rupture, in whom retinal detachment with proliferative vitreoretinopathy developed.

RESULTS

The early onset and the severe clinical course of proliferative vitreoretinopathy in these eyes showed parallels to traumatic proliferative vitreoretinopathy. The retina in all eyes could be reattached.

CONCLUSION

The authors point out the necessity for accurate and close follow-up and early, extensive surgical treatment in Terson syndrome, especially in patients with a reduced general state of health.

Terson's syndrome in a patient with acute promyelocytic leukemia on all-trans retinoic acid treatment

The syndrome of vitreous hemorrhage in association with any form of intracranial bleeding is known as Terson's syndrome. Acute promyelocytic leukemia (APL) constitutes 5% to 15% of cases of acute nonlymphocytic leukemias, in which hemorrhagic diathesis often occurs and results in a rapid fatal outcome. In this report we describe a patient with APL who developed cerebral bleeding in association with bilateral subhyaloid and vitreous hemorrhages consistent with Terson's syndrome while she was on all-trans retinoic acid induction therapy.

Retinal folds in Terson syndrome

BACKGROUND

Perimacular retinal folds have been reported in the shaken baby syndrome, but have not been described in adults with Terson syndrome.

METHODS

The authors present two patients with perimacular retinal folds in adults with Terson syndrome. In one patient, electron microscopy was used to examine the membrane spanning the fold.

RESULTS

The membrane spanning the perimacular fold was found to be internal limiting membrane. The pathogenesis of these perimacular folds found in adults sustaining direct head trauma is probably different from that previously described for folds seen in infant eyes with shaken baby syndrome.

CONCLUSION

Retinal folds occurring in Terson syndrome are clinically similar to those seen in the shaken baby syndrome.