Terson's syndrome. Clinicopathologic correlations

Clinical Applications of Ultrasonography in Neurocritically Ill Patients

Ultrasonography is part of the multimodal monitoring of the neurocritical patient. Through transcranial color Doppler ultrasound, carotid-color Doppler ultrasound, and ocular ultrasound it is possible to diagnose and monitor a multitude of pathological conditions, such as cerebrovascular events, vasospasm, Terson syndrome, carotid atheromatosis, and brain death. Furthermore, these techniques enable the monitoring of the intracranial pressure, the cerebral perfusion pressure, and the midline deviation, which allows us to understand the patient's neurocritical pathology at their bedside, in a noninvasive way. Although none of these tools have yet been shown to improve patient prognosis, the dissemination of knowledge and management of neurovascular ultrasonography could significantly improve the comprehensive management of neurocritical patients.

Reliability of Preoperative Ultrasonography Evaluation for Vitreoretinal Surgery

To evaluate the present level of reliability of common ultrasonography prior to vitreoretinal surgery, we carried out a prospective study to compare preoperative ultrasonography data with direct intraoperative findings. A total of 228 eyes with different vitreoretinal disorders and opaque or clear media were studied. In the group of 187 eyes with fractional retinal detachment (group I), the percentage of agreement between the ultrasonography data and the surgical fingings ranged from 77.1% to 92.2%, depending on the pathology. In the group of 41 eyes without retinal detachment (group II), agreement ranged from 90.4% to 100%. The most frequent causes of failure of preoperative ultrasonography were incorrect prediction of macular detachment, partial posterior vitreous detachment, posterior vitreoschisis and vitreoretinal adhesions. The main cause of failure was the presence of multiple complicated echos in group I, particularly in fractional diabetic retinal detachment. To achieve maximum benefits from ordinary preoperative ultrasonography, the vitreoretinal surgeon must be fully aware of its present level of reliability and general limitations.

Pars Plana Vitrectomy for Terson's Syndrome—Visual Outcome and Impact on Postintracranial Hemorrhage Rehabilitation

We report the visual outcomes and change in the Modified Barthel Index Score (BIS) in four patients with Terson's syndrome treated with vitrectomy. A retrospective study of four patients with Terson's syndrome from Royal Prince Alfred Hospital, Sydney, was carried out. Assessment of visual acuity and physical disability pre- and post-vit rectomy using the Snellen Chart and the Barthel Index, respectively, was performed. All four patients were found to have improved visual acuity and BIS post vitrectomy. Improved vision from treatment of vitreous hemorrhage decreases the disability after intracranial hemorrhage and Terson's syndrome. Early diagnosis and management would shorten the rehabilitation process and improve the quality of life. Ophthalmo logic management depends on the severity of vitreous hemorrhage, whether it is uni lateral or bilateral, and its impact on patient's daily function. Key Words: Terson's syn drome—Subarachnoid hemorrhage—Vitreous hemorrhage—Vitrectomy—Visual acuity—Modified Barthel Score Index.

Ocular ultrasound as an easy applicable tool for detection of Terson's syndrome after aneurysmal subarachnoid hemorrhage

Introduction

Intraocular hemorrhage in patients suffering from aneurysmal subarachnoid hemorrhage is known as Terson's syndrome and is an underestimated but common pathology. We therefore designed a prospective single-blinded study to evaluate the validity of ocular ultrasound compared to the gold standard indirect funduscopy in the diagnosis of Terson's syndrome.

Material and Methods

Fifty-two patients (104 eyes in total) suffering from aneurysmal subarachnoid hemorrhage were enrolled in this study. Two investigators independently performed a single-blinded ocular ultrasound using a standard intensive care ultrasound system to detect an intraocular hemorrhage. Indirect funduscopy following iatrogenic mydriasis served as the gold standard for confirmation or exclusion of an intraocular hemorrhage. Statistical analyses were performed to evaluate the sensitivity and specificity, positive and negative predictive values of the method as well as the learning curve of ocular ultrasound.

Results

Indirect funduscopy detected Terson's syndrome in 11 of 52 (21.2%) respectively in 21 of 104 (20.2%) eyes in patients suffering from subarachnoid hemorrhage. Sensitivity and specificity increased with the number of ocular ultrasound examinations for both investigators, reaching 81.8% and 100% respectively. Positive and negative predictive values were different for both investigators (63.6% vs. 100% positive and 100% vs. 95.7% negative) but were both correlated to the amount of intraocular hemorrhage. A low Glasgow Coma scale (p = 0.015) and high Hunt & Hess grade (p = 0.003) was associated with a higher rate of Terson's syndrome.

Conclusions

Ocular ultrasound using standard ultrasound equipment has been confirmed as a reliable, easy-to-handle bedside screening tool for detecting Terson's syndrome. Nevertheless funduscopy remains the gold standard to detect Terson's syndrome.

Comparison of CT and clinical findings of Terson's syndrome in 121 patients: a 1-year prospective study

Object

Terson's syndrome (TS) is a vitreous hemorrhage in association with subarachnoid hemorrhage (SAH). Its diagnosis is often delayed, which may result in vision loss secondary to treatable conditions. Methods to hasten early diagnosis and consequent ophthalmic referral are desirable. The aims of this study were 1) to assess the specificity and sensitivity of conventional head CT for diagnosing TS in patients with aneurysmal SAH (aSAH); and 2) to determine the incidence of TS and its association with age, sex, aSAH severity, and overall mortality.

Methods

Patients admitted to Helsinki University Central Hospital who underwent surgery or endovascular treatment for a ruptured intracranial aneurysm during 2011 were participants in this prospective study. They underwent serial dilated fundoscopic examinations during a 6-month period. Two radiologists independently reviewed ocular findings suggestive of TS on conventional CT head scans obtained in all patients as a routine diagnostic procedure. Associations between TS and relevant clinical, radiological, and demographic data were analyzed with uni- and multivariate logistic regression.

Results

Of 121 participants, 13 (11%) presented with TS, and another 22 (18%) with intraretinal hemorrhages. For reviewing CT head scans, the overall observed agreement between the 2 raters was 96% (116 of 121 cases), with a substantial κ of 0.69 (95% CI 0.56–0.82). The sensitivity of the CT findings for TS was 42%, and the specificity was 97%. Associations of the World Federation of Neurosurgical Societies (WFNS) and Hunt and Hess grades on admission, the presence of intracerebral hemorrhage, female sex, and aneurysm length with TS were all statistically significant. Logistic regression demonstrated that sex and WFNS grade were independently associated with TS and provided the best fit to the data.

Conclusions

Routinely looking for TS findings in CT head scans may prove valuable in clinical practice. Terson's syndrome is associated with female sex and poor clinical condition on admission.

[Subhyaloid macular haemorrhage in Terson syndrome, treated by rupture of the posterior hyaloid using YAG laser]

CASE REPORT

We present the case of a 48 year-old man who had a sudden onset of vomiting, headache and loss of consciousness. The visual acuity was severely reduced in the left eye, with a large subhyaloid haemorrhage being observed in the fundus.

DISCUSSION

The combination of subarachnoid haemorrhage and a vitreous haemorrhage is called Terson syndrome. The details of the treatment of this case with YAG laser are also discussed.

Possible methods of blood entrance in Terson syndrome

BACKGROUND AND OBJECTIVE

To present spectral domain optical coherence tomography (SD-OCT), scanning laser ophthalmoscopy, and intraoperative images showing possible pathways of blood entrance into the eye and ways in which it may spread inside the eye in Terson syndrome.

PATIENTS AND METHODS

Nine eyes of 5 patients with Terson syndrome underwent pars plana vitrectomy. Surgeries were recorded and analyzed afterward. SD-OCT and scanning laser ophthalmoscopy examinations were performed after surgery.

RESULTS

Visual acuity improved in all cases. SD-OCT three-dimensional mode improved visualization of the internal limiting membrane (ILM), possibly due to sub-ILM blood spreading detachment near the macula and optic disc. Scanning laser ophthalmoscopy revealed blood spreading along vessels and blood under the retina was observed intraoperatively.

CONCLUSION

SD-OCT, scanning laser ophthalmoscopy, and intraoperative images show that blood may enter the vitreous cavity around the retinal vessels near the optic disc. Inside the eye, the blood may spread intraretinally, sub-ILM, or along the retinal vessels.

Terson Syndrome from a Significant Cerebral Infarct Occurring During the Peripartum Period

This case report describes a 23-day-old infant with significant infarct in the right middle cerebral artery territory associated with intraparenchymal hemorrhage within the infarct, subdural hygroma, and bilateral intraocular hemorrhage. The features, severity, and timing of the pathology are suggestive of Terson syndrome that has occurred during the peripartum period.

Retinal haemorrhages in- head trauma resulting from falls: differential diagnosis with non-accidental trauma in patients younger than 2 years of age

INTRODUCTION

Falls are a common chief complaint among children seeking medical attention in emergency departments and are the leading cause of injuries requiring hospitalisation. Falls are also a frequent excuse to conceal cases of maltreatment in small children. Retinal haemorrhages could be a useful marker for their differential diagnosis.

OBJECTIVE

This study aims to determine the prevalence and characteristics of retinal haemorrhages in children with head trauma resulting from a vertical fall.

MATERIALS AND METHODS

This was a prospective study of children younger than 2 years of age admitted to the hospital with head trauma from a vertical fall. The circumstances of the falls and injuries were analysed. All children were evaluated by an ophthalmologist for retinal haemorrhage.

RESULTS

One hundred fifty-four patients were included. Eighty-three percent of the falls were from a height equal to or less than 120 cm. The most common mechanism of injury was fall from a stroller followed by rolling off the bed. Sixteen children had evidence of intracranial injuries. Three patients had retinal haemorrhages (prevalence 1.9%; 95%CI, 0.4-5.6%), all unilateral, in association with severe epidural haematoma with a midline shift. The detection of retinal haemorrhages could be related to the presence of intracranial injury but not with the circumstances of the fall.

DISCUSSION AND CONCLUSIONS

Any cranial injury from a vertical fall that produces severe epidural bleeding can also cause retinal haemorrhages, mainly unilateral. The finding of diffuse and bilateral retinal haemorrhages or their presence in the absence of this type of intracranial haemorrhage must continue to point out another cause different from the fall as origin of the traumatism, being necessary to exclude non-accidental trauma.

Terson syndrome with bilateral optic nerve sheath hemorrhage

A 53-year-old man presented with an acute headache and mental status changes due to rupture of an anterior choroidal artery aneurysm. A preoperative CT scan demonstrated subarachnoid hemorrhage, bilateral optic nerve sheath hemorrhage, and bilateral intraocular hemorrhage. Ophthalmoscopy and B-scan ocular ultrasound disclosed vitreous hemorrhages, features consistent with Terson syndrome. This is the first CT report of Terson syndrome showing bilateral optic nerve sheath hemorrhage.

Vitrectomy for premacular hemorrhagic cyst in children and young adults

BACKGROUND

A pre-macular accumulation of blood is termed a hemorrhagic macular cyst and may be found both in eyes with Terson's syndrome and in shaken baby syndrome. In this study, we report on our experience and results of vitreoretinal surgery for treatment of pre-macular hemorrhagic cyst in eyes of patients suffering from Terson's syndrome and shaken baby syndrome.

PATIENTS AND METHODS

Between November 1995 and May 2003 seven eyes of six children underwent vitrectomy for pre-macular hemorrhagic cyst. Patients' age ranged from 5 months to 17 years. Indication for vitreoretinal surgery was pre-macular hemorrhagic cyst in eyes with Terson's syndrome (n=5) and shaken baby syndrome (n=2). During vitrectomy, rhexis of internal limiting membrane was performed. Four children received intensive orthoptic treatment postoperatively.

RESULTS

All eyes in our series showed a submembranous localization of pre-macular hemorrhagic cyst. The results of electron microscopic examination showed that the excised anterior walls contain internal limiting membrane. In all eyes improvement of the anatomic situation and of visual acuity was achieved. Duration of follow-up ranged from 6 months to 5 years.

CONCLUSIONS

Vitrectomy for hemorrhagic macular cyst in children is a safe and effective alternative to observation, offering visual rehabilitation, especially if amblyopia has developed or if both eyes are affected. If a hemorrhagic macular cyst is encountered, its complete removal is recommended to prevent development of proliferative vitreoretinopathy.

The natural history of nontraumatic subarachnoid hemorrhage-related intraocular hemorrhages

PURPOSE

To describe the natural history of intraocular hemorrhages related to subarachnoid hemorrhage (SAH) as a result of ruptured intracranial aneurysms.

METHODS

Retrospective review of patients with cerebral aneurysms examined by a referral neuro-ophthalmology service between 1980 and 1998. Patients with intraocular hemorrhages associated with SAH as a result of ruptured aneurysms were followed up without vitrectomy, unless bilateral vitreous hemorrhage occurred.

RESULTS

Seventy of 450 patients with cerebral aneurysms had an SAH. Of these, 30 eyes of 19 patients had intraocular hemorrhages. Fourteen eyes had a vitreous hemorrhage; 12 had subhyaloid blood without a vitreous hemorrhage; and four had retinal hemorrhages alone. Two patients died shortly after presentation. Twenty-eight eyes were followed up for a mean of 4.8 years. Initial visual acuity was 20/100 to light perception in eyes with a vitreous hemorrhage, 20/20 to 20/400 in eyes with subhyaloid blood, and 20/20 to 20/40 in eyes with retinal hemorrhages. Three of the 12 eyes with a vitreous hemorrhage underwent vitrectomy. Of the nonoperated eyes, final visual acuity was at least 20/30 in 19 (76%) eyes, 20/40 to 20/60 in four (16%) eyes, and 20/100 in both eyes of one patient with premacular subhyaloid blood. None of the nonoperated eyes developed cataract formation or progression, retinal tears, or retinal detachment. Epiretinal membrane developed in one eye and pigmentary maculopathy developed in five.

CONCLUSIONS

Except for patients with bilateral vitreous hemorrhages, early vitrectomy may not be necessary in most cases of intraocular hemorrhages associated with nontraumatic SAH.

Retinal findings in children with intracranial hemorrhage

PURPOSE

To identify the incidence of Terson's syndrome in children.

DESIGN

Prospective, observational case series.

PARTICIPANTS

Fifty-seven consecutive children with known intracranial hemorrhage from nonabuse causes.

METHODS

Dilated fundus examination to detect intraretinal hemorrhages or other abnormalities.

MAIN OUTCOME MEASURES

Presence or absence of intraretinal hemorrhages or other abnormalities.

RESULTS

Fifty-five patients (96%) had no evidence of intraretinal or vitreous hemorrhage. Two patients had abnormal retinal examinations. One patient had a single dot hemorrhage associated with presumed infectious white retinal lesions. The second patient had three flame and two deeper dot intraretinal hemorrhages after a motor vehicle accident (1.5% incidence of retinal hemorrhage).

CONCLUSIONS

Retinal hemorrhage is uncommon in children with intracranial hemorrhage not resulting from shaken baby syndrome. The maximal incidence of intraretinal hemorrhage in children with nonabuse intracranial hemorrhage is 8%.

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.

Postmortem endoscopy of the ocular fundus. A valuable tool in forensic postmortem practice

Pathological changes of the ocular fundus in acute severe head or extracranial injury are difficult to document. In vivo examination usually has to be carried out under intensive care conditions. Postmortem ophthalmoscopy is usually impeded by rapid blurring of the cornea. Therefore, endoscopic fundal photography has been applied by using a pars plana approach during forensic postmortem procedures. This technique provides fundoscopic pictures of high quality as a valuable supplement for subsequent macro- and histopathological preparations and sections. Different patterns of fundoscopic findings seem to correspond to different types of injuries such as craniocerebral trauma, traumatic asphyxia and decompression sickness, and may allow some insight into the respective pathogenetic mechanism.

Benign idiopathic haemorrhagic retinopathy

PURPOSE

To describe a new condition characterised by an unusual unilateral idiopathic haemorrhagic retinopathy.

METHODS

A review is presented of patient histories from 5 patients with acute-onset unilateral idiopathic haemorrhagic retinopathy, including results of ophthalmological, haematological and fluorescein angiographic examinations.

RESULTS

All patients had an extensive deep blot haemorrhagic retinopathy without significant vascular signs or abnormal optic discs. In 4 cases the haemorrhage was sufficiently severe to break through into the vitreous. Fluorescein angiography demonstrated normal arteriovenous flow, without capillary non-perfusion, vessel or disc leakage. Disc swelling, macular oedema and cotton wool spots were not seen at any stage in these patients. All patients recovered the visual acuity in the affected eye by 4 months. Systemic examination in all cases was unremarkable.

CONCLUSION

This distinct and rare form of retinopathy is important to define since it has a good prognosis without treatment.

Intraorbital rupture of a cavernous internal carotid artery aneurysm: therapeutic options

PURPOSE

To describe the use of an endovascular therapeutic technique in the management of a giant carotid cavernous aneurysm.

METHODS

We reviewed the clinical and neuroradiologic findings of a patient with an unusual case of carotid cavernous aneurysm and intraorbital rupture. The medical literature was searched for similar cases and to review the use of endovascular techniques.

RESULTS

The patient was treated by balloon occlusion of the left internal carotid artery.

CONCLUSIONS

Endovascular techniques can be used to treat complex giant cranioorbital cavernous aneurysms.

Indocyanine green-assisted peeling of the retinal internal limiting membrane

OBJECTIVE

To determine whether indocyanine green (ICG) stains and facilitates peeling of the retinal internal limiting membrane (ILM). To investigate the different staining properties of the posterior cortical hyaloid, retinal ILM, and the retina after ILM removal.

DESIGN

Autopsy eye study.

MATERIALS

Eleven human cadaveric eyes.

METHODS

Open sky vitrectomy including removal of the posterior cortical vitreous was performed. A 0.5% ICG solution was then injected into the posterior vitreous cavity over the macula. The dye was allowed to settle on the macula for 5 minutes and was then removed by mechanical aspiration. Peeling of the ILM was initiated with a bent needle and completed with intraocular forceps. Specimens were submitted for light and electron microscopy.

MAIN OUTCOME MEASURES

Staining properties and ease of peeling of retinal ILM were evaluated. Retinal ILM removal was confirmed by histopathologic and electron microscopic examination.

RESULTS

ICG contact with the retinal surface resulted in bright green staining of the ILM. This stain greatly facilitated ILM peeling by improving direct visualization of the membrane. The underlying retina did not stain, thus providing a clear distinction between the stained ILM and the unstained retina. Continuous circular peeling of the ILM was easily completed with this technique. Light microscopic and ultrastructural studies confirmed removal of the ILM.

CONCLUSIONS

ICG solution distinctly stains the nearly invisible retinal ILM in human cadaveric eyes. ICG staining greatly facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina.

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.

Screening for ocular hemorrhages in patients with ruptured cerebral aneurysms: a prospective study of 99 patients

BACKGROUND

Terson's syndrome (vitreous hemorrhage) and other ocular hemorrhages (retinal hemorrhages) have been reported to occur in up to 40% of patients with ruptured cerebral aneurysms. Because microsurgical vitrectomy can safely restore vision in patients with visual loss secondary to Terson's syndrome, we hypothesized that prospectively screening a selected group of patients with aneurysms would result in a higher rate of vitrectomy in patients with more extensive subarachnoid hemorrhage.

METHODS

Ninety-nine patients with ruptured cerebral aneurysms were prospectively screened for Terson's syndrome and other forms of ocular hemorrhage by an ophthalmologist. Follow-up data were obtained for seven of eight cases of Terson's syndrome, and vitrectomy was performed for visual restoration when indicated.

RESULTS

Ocular hemorrhages were present in 17% of patients with ruptured cerebral aneurysms, and Terson's syndrome was present in 8% of patients. Screening of patients with histories of transient or prolonged comas sensitively identified patients with ocular hemorrhages in 100% of the patients with Terson's syndrome and 89% of the patients with other ocular hemorrhages. Fifty-five percent of the patients in the overall series had histories of transient or prolonged comas, and 53% (specificity) of those patients had ocular hemorrhages. Two of the eight patients with Terson's syndrome underwent vitrectomy, with dramatic improvement in vision. No other ocular hemorrhages required surgery.

CONCLUSIONS

Ophthalmological screening of patients with histories of transient or prolonged comas after ruptured cerebral aneurysms very sensitively identifies patients with ocular hemorrhages, which are relatively common in patients with subarachnoid hemorrhage treated in an academic neurosurgical practice. The present study underestimates the true incidence of Terson's syndrome in that patients who died shortly after their subarachnoid hemorrhage were not included. Vitrectomy for patients who do not exhibit spontaneous improvement in vision results in a dramatic reversal of blindness.

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.

Terson's syndrome in spontaneous subarachnoid hemorrhage: a prospective study in 60 consecutive patients

Sixty consecutive patients with spontaneous subarachnoid hemorrhage (SAH) were prospectively studied by means of indirect funduscopy to address the question of incidence and prognostic implications of Terson's syndrome (TS) after SAH. Terson's syndrome was diagnosed in 10 (16.7%) of 60 patients and was associated with subarachnoid rebleeding in seven of 10. No correlation was found between anatomical localization of the ruptured aneurysm and TS laterality. Case fatality was nine (90%) of 10 in patients with TS compared to five (10%) of 50 in non-TS patients. It is concluded that TS is not infrequent (16.7%) in spontaneous SAH and has a poor prognosis, often heralding subarachnoid rebleeding.

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.

Retinal findings after head trauma in infants and young children

BACKGROUND

Many authorities believe that the finding of retinal hemorrhages in a child younger than 3 years of age with a history of head trauma, in the absence of an obvious cause for the injury, is pathognomonic of child abuse. To date, no studies have examined the prospective retinal examination of children who have had head trauma. The authors undertook such a study because the presence of retinal hemorrhage from any head trauma in children may have medicolegal diagnostic significance in differentiating accidental from nonaccidental trauma.

METHODS

Seventy-nine children younger than 3 years of age, each of whom experienced head injury, underwent an ophthalmologic assessment, which included a dilated funduscopic examination.

RESULTS

Seventy-five children sustained accidental head injuries and had normal funduscopic examinations. Three children had nonaccidental head injuries and all were found to have varying degrees of retinal hemorrhages. One child, with a normal fundus examination, had injuries that were of indeterminate cause.

CONCLUSION

The finding of retinal hemorrhages in a child with a head injury suggests a nonaccidental cause.

Terson's syndrome: a reversible cause of blindness following subarachnoid hemorrhage

Terson's syndrome refers to the occurrence of vitreous hemorrhage with subarachnoid hemorrhage (SAH), usually due to a ruptured cerebral aneurysm. Although it is a well-described entity in the ophthalmological literature, it has been only rarely commented upon in the neurosurgical discussion of SAH. Fundus findings are reported in a prospective study of 22 consecutive patients with a computerized tomography- or lumbar puncture-proven diagnosis of SAH. Six of these patients had intraocular hemorrhage on initial examination. In four patients vitreous hemorrhage was evident on presentation (six of eight eyes). In the subsequent 12 days, vitreous hemorrhage developed in the additional two patients (three of four eyes) due to breakthrough bleeding from the original subhyaloid hemorrhages. The initial amount of intraocular hemorrhage did not correlate with the severity of SAH. Two of the six patients with intraocular hemorrhage died, whereas five of the 16 remaining SAH patients without intraocular hemorrhage died. Of the four survivors with intraocular hemorrhage, three showed gradual but significant improvement in their visual acuity by 6 months. The fourth underwent vitrectomy at 8 months after presentation and had a good visual result. With modern and aggressive medical and microsurgical management, Terson's syndrome should be recognized as an important reversible cause of blindness in patients surviving SAH.

Long-term visual outcome in Terson syndrome

The presentation and long-term visual outcome in 30 eyes with Terson syndrome is evaluated. In 25 of 30 eyes (83%), visual acuity of 20/50 or better was attained. This occurred in 12 of 16 eyes (75%) managed by observation alone and 12 of 14 eyes (86%) treated by pars plana vitrectomy. The most common long-term sequelae in all eyes studied was the formation of an epiretinal membrane. These occurred in 14 of 18 eyes (78%) followed for 3 or more years but accounted for significant visual loss in only 2 eyes. There was no difference in final visual outcome between those patients undergoing vitrectomy and those managed conservatively. However, visual recovery was more rapid in eyes undergoing vitrectomy despite the fact that vitrectomy was reserved for eyes with more dense vitreous hemorrhage.