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

Factors affecting anatomical and visual outcomes in Terson syndrome managed by surgery or observation

OBJECTIVES

To investigate visual outcomes and prognostic factors of patients with Terson syndrome (TS) managed with observation or pars plana vitrectomy (PPV).

METHODS

retrospective review of medical records of 117 eyes from 81 patients (43 females) with TS. Main outcome measures were final best corrected visual acuity (BCVA), intraoperative findings and long-term sequelae.

RESULTS

46 (39.3%) eyes were managed conservatively and 71 (60.7%) eyes underwent PPV. Median follow-up was 8.4 months. The PPV group had significantly worse (p < 0.001) baseline BCVA (median 2.3 versus 0.7 logMAR, Snellen equivalent 20/4000 versus 20/100). Final BCVA did not differ between the two groups (p = 0.38). Final BCVA ≥ 0.3 logMAR (20/40) in the surgery group was associated with post-operative retinal detachment (p = 0.013) and macular abnormalities (p = 0.014), and in the observation group with ocular comorbidity (p = 0.008). Retinal breaks were detected intraoperatively in 25 (35.2%) eyes and were associated with an interval longer than 3 months between ocular diagnosis and surgery (p = 0.04), but not with larger gauge instrumentation and posterior vitreous detachment. Incidence of ERM did not differ among patients managed conservatively and after PPV (p = 0.9) and between eyes undergoing early or delayed surgery (p = 0.09). The most common post-operative complications were cataract in 16 (22.5%) eyes and ERM in 8 (11.3%) eyes.

CONCLUSIONS

visual outcomes in TS are similar with both management strategies. Surgery allows faster and greater visual recovery but carries high risk of intraoperative retinal tears if delayed for longer than 3 months from initial presentation. ERM and retinal detachment are not correlated with timing of surgery or management strategy.

PHOTORECEPTOR DAMAGE IN TERSON SYNDROME

PURPOSE

To describe photoreceptor damage in patients with Terson syndrome as a potential cause for inconsistent clinical outcomes.

METHODS

Clinical evaluation and retinal imaging in six patients.

RESULTS

Four patients were women and two men, with an average age of 46.8 years (SD 8.9). Four patients suffered aneurysmal subarachnoid hemorrhage, one vertebral artery dissection, and one superior sagittal sinus thrombosis. In 11 eyes, a consistent pattern of outer retinal changes within the central retina affecting the ellipsoid zone and the outer nuclear layer was observed, indicating photoreceptor damage. Areas of photoreceptor damage showed poor spatial correlation with intraocular hemorrhage, particularly subinternal limiting membrane hemorrhage. The observed retinal abnormalities demonstrated incomplete recovery over long-term follow-up 3.5 to 8 years posthemorrhage, irrespective of surgical or conservative treatment strategy, and had variable impact on the patients' visual function.

CONCLUSION

The observations suggest that photoreceptor damage in Terson syndrome likely represents a distinct manifestation of this condition, which could be caused by transient ischemia of the outer retina secondary to acute rise in intracranial pressure.

Terson Syndrome - Clinical Presentation, Management, and Visual Outcomes in a Tertiary Centre

Purpose

The purpose of this study was to characterize the clinical presentation, management strategy and visual outcomes of patients diagnosed with Terson syndrome and followed in a tertiary centre in Portugal.

Patients and Methods

A single-centre retrospective study was performed, based on the survey review of the medical records of every consecutive patient diagnosed with Terson syndrome and followed from January 2018 to August 2021. The change in best-corrected visual acuity (BCVA) from baseline to the final evaluation was the primary outcome.

Results

Fifteen eyes from 8 patients (50% female) were included. The mean age at diagnosis was 55±7 years. The neurological event was traumatic brain injury in 37.5% (n=3) and subarachnoid haemorrhage in 62.5% of the patients (n=5). Bilateral intraocular haemorrhage occurred in 875% (n=7) of the patients. Vitreous and preretinal haemorrhages occurred each in 66.7% (n=10), intraretinal in 30% (n=3) and subretinal in 13.3% (n=2) of the eyes. In 40% of the eyes (n=6), spontaneous resolution of intraocular haemorrhage occurred, while PPV was performed in the remaining 60% (n=9). Ocular haemorrhage detection occurred 58.47 ± 40.94 days after the neurological event (range 11 to 121 days). Baseline BCVA was 1.11 ± 1.01 logMAR and improved to 0.32 ± 0.69 logMAR in the follow-up period (p=0.004). A positive correlation was found between initial and final BCVA (Spearman's rho = 0.643, p=0.01). Baseline BCVA of eyes undergoing PPV was lower than of those conservatively managed (1.84±0.72 vs 0.20±0.28 logMAR, p<0.001). However, there were no statistically significant differences in final BCVA after surgery or observation (0.56 ± 0.90 vs 0.04 ± 0.04 logMAR, p=0.149). Longer periods between the neurological and the ophthalmological diagnosis were correlated with worse final BCVA (Spearman's rho = 0.688, p=0.005).

Conclusion

Terson syndrome is a potential cause of irreversible visual loss. Diagnosis delay may affect visual prognosis. PPV is indicated when intraocular haemorrhage is dense and does not resolve spontaneously or when visual acuity at presentation is low, allowing for good visual outcomes with minimal complications.

Terson syndrome: Two case reports

Purpose

Vitreous or retinal hemorrhage occurring in association with subarachnoid hemorrhage (SAH) is known as Terson syndrome (TS). Its incidence is of the order of 10–50% after subarachnoid hemorrhage. We report two cases of TS with different clinical presentations, different managements, and a good final prognosis, which were managed at the Ibn Rochd hospital in Casablanca.

Observations

We report two cases of TS. The first one occurred in a 55-year-old hypertensive man following a ruptured aneurysm of the internal carotid artery, revealed by a decrease in visual acuity concomitant with the neurological symptomatology. The evolution was favorable after specialized neurological management and spontaneous resorption of the intravitreal hemorrhage was obtained 3 months after the acute episode with good visual recovery. The second case was that of a 45-year-old man who presented with an intravitreal hemorrhage of the right eye, 24 h after severe head trauma responsible for a bifrontal extradural hematoma. The B-mode ocular ultrasound discovery of a retinal detachment with persistent hemorrhage led to the indication of a pars plana vitrectomy with retinal tamponade, which allowed visual rehabilitation without recurrence after 1 year.

Conclusions

Ophthalmologic evaluation by specialized examination and radiology (ocular ultrasound, OCT) is necessary for all patients with TS because early diagnosis and treatment can prevent visual loss and associated complications. Treatment of TS can be conservative and based on periodic monitoring. A pars plana vitrectomy is considered in some cases.

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The etiopathogenesis of TS has been controversial since its appearance.

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The latest studies speak of a mechanism: the theory of glymphatic reflux

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TS may occur in an atraumatic context but there is often the notion of intracranial hyperpressure.

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The prognosis remains better in the absence of other complications and cases of early and adequate management.

Terson's syndrome, the current concepts and management strategies: A review of literature

Terson's Syndrome describes intraocular hemorrhage secondary to an acutely raised intracranial pressure (ICP). Although Terson's Syndrome is common amongst patients with subarachnoid hemorrhage (SAH), it is underdiagnosed and often overlooked. This review discusses the current understanding of the etiopathogenesis, clinical features, and management of Terson's Syndrome and highlights the visual and prognostic implications to stress the importance of timely diagnosis and management. The origin of intraocular hemorrhage in Terson's Syndrome has been debated. A recognized theory suggests that an acutely raised ICP induces effusion of cerebrospinal fluid into the optic nerve sheath which dilates the retrobulbar aspect of the sheath in the orbit. Dilatation mechanically compresses the central retinal vein and retinochoroidal veins resulting in venous hypertension and rupture of thin retinal vessels. A commonly reported clinical feature is decreased visual acuity and blurred vision. These may be accompanied by symptoms of increased ICP including loss of consciousness and headache. Diagnosis is established using evidence from the clinical presentation, ophthalmoscopy, and, when required, imaging including B-mode ultrasound, CT, MRI, and fluorescein angiography. Terson's Syndrome is managed conservatively by observation for mild cases and with vitrectomy for bilateral cases and for patients whose hemorrhage has not spontaneously resolved after an observational period. Terson's Syndrome can be used as a prognostic indicator of morbidity and mortality in underlying pathology like SAH. Fundoscopy of patients with SAH, acutely raised ICP or visual disturbance with unknown etiology can help establish a timely Terson's Syndrome diagnosis. This may avoid the risk of permanent visual impairment.

An explanation for Terson syndrome at last: the glymphatic reflux theory

Terson Syndrome (TS) describes the presence of intraocular hemorrhage in patients with intracranial hemorrhage, typically subarachnoid hemorrhage. Despite TS being a well-defined and frequently occurring phenomenon, its pathophysiology remains controversial. This review will present the current understanding of TS, with view to describing a contemporary and more plausible pathomechanism of TS, given recent advances in ophthalmic science and neurobiology. Previously proposed theories include a sudden rise in intracranial pressure (ICP) transmitted to the optic nerve sheath leading to rupture of retinal vessels; or intracranial blood extending to the orbit via the optic nerve sheath. The origin of blood in TS is uncertain, but retinal vessels appear to be an unlikely source. In addition, an anatomical pathway for blood to enter the eye from the intracranial space remains poorly defined. An ocular glymphatic system has recently been described, drainage of which from the globe into intracranial glymphatics is reliant on the pressure gradient between intraocular pressure and intracranial pressure. The glymphatic pathway is the only extravascular anatomical conduit between the subarachnoid space and the retina. We propose that subarachnoid blood in skull base cisterns near the optic nerve is the substrate of blood in TS. Raised ICP causes it to be refluxed through glymphatic channels into the globe, resulting in intraocular hemorrhage. We herewith present glymphatic reflux as an alternative theory to explain the phenomenon of Terson Syndrome.

Unilateral Terson-Like Syndrome in a Patient With a Perinatal Ischemic Stroke

Terson syndrome typically presents with bilateral hemorrhagic retinopathy associated with acute intracranial bleeding. The authors present a case of neonatal hemispheric ischemic stroke with vasogenic edema and increased intracranial pressure creating a unilateral Terson-like syndrome. Magnetic resonance imaging indicated congenital occlusion of the left internal carotid artery, among other vascular abnormalities. Chronic submacular, peripheral subretinal, and vitreous hemorrhage were observed, suggesting a multilaminar hemorrhagic process resembling Terson syndrome without frank intracranial hemorrhage. The patient underwent successful lens-sparing vitrectomy of the left eye. A unilateral Terson-like syndrome can result from severe cerebral edema following neonatal stroke in the setting of multiple congenital cerebrovascular abnormalities. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:592-595.].

"Arcus retinalis": A novel clinical marker of sub-internal limiting membrane hemorrhage

INTRODUCTION

Preretinal hemorrhages can be located in subhyaloid or sub-internal limiting membrane (ILM) space. Though optical coherence tomography (OCT) may help to distinguish the exact location of hemorrhage in selected cases, it is often difficult to discern clinically. The purpose is to describe a novel clinical sign named "arcus retinalis" as a clinical marker of sub-ILM hemorrhage.

METHODS

Retrospective observational case series. Ophthalmic records of 31 eyes with sub-ILM hemorrhage were analyzed. The sub-ILM nature of the hemorrhage was confirmed either by the presence of two distinct layers (ILM and posterior hyaloid) on OCT or on intraoperative sub-ILM localization of the hemorrhage during vitrectomy.

RESULTS

15 out of 31 eyes with sub-ILM hemorrhage demonstrated a retinal yellowish-white arc corresponding to the outer margin of the sub-ILM hemorrhage. A complete circle was not seen in most of the cases. This arc corresponded to a vertical peg-like structure in the outer retina on OCT and had a tendency to fade away over months. In 10 eyes, it was visible at presentation and in five eyes it could only be seen after clearing of the hemorrhage.

CONCLUSION

Retinal yellowish-white arc ("arcus retinalis") is a useful clinical marker of sub-ILM hemorrhage with distinct OCT features that tends to disappear with time.

Clinical observations and considerations in the treatment of Terson syndrome using 23G vitrectomy

PURPOSE

This retrospective study analyzed the results of 23G vitrectomy for the treatment of intraocular hemorrhage in patients with Terson syndrome. The pathogenesis of Terson syndrome and the timing of vitrectomy are discussed.

METHODS

Eight eyes of eight patients were included in the study. Intrasurgical images were acquired, and membranes peeled off during surgery were subjected to pathological staining. Postoperative examination included visual acuity, intraocular pressure, funduscopy, and optical coherence tomography angiography.

RESULTS

The course of visual impairment in the patients ranged from < 1 to 5 months; visual acuity ranged from light perception to 20/1000. Surgeries in the eight patients were all successful, and no severe complications were observed. Visual acuity improved in each operative eye. Pathological staining revealed only fibrous connective tissue, and no nerve fibers in the membranes peeled off during surgery. Optical coherence tomography angiography revealed no changes in blood vessel density in the inner layer of the retina of the operative eye compared with the non-operative eye in each patient.

CONCLUSIONS

Timely surgical intervention is necessary for the treatment of intraocular hemorrhage in patients with Terson syndrome. Clinical findings support the theory that intraocular blood results from stasis or rupture of retinal superficial peripapillary vessels caused by elevated intracranial pressure.

Different approaches in the management of macular hemorrhage: Case reports and a literature review

Introduction

Macular hemorrhages result in a sudden and profound loss of vision. The primary treatment modalities include observation, intravitreal injection of antiangiogenic drugs, neodymium-doped yttrium aluminum garnet hialoidotomy, intravitreal injection of gas with or without tissue plasminogen activator, as monotherapy or combined with surgery. In this paper, we report four cases of macular hemorrhages of different causes treated with different approaches, and we review the literature in this regard.

Case presentation

All four patients presented different causes of macular hemorrhage. The first case had a preretinal hemorrhage due to a Valsalva retinopathy and was treated with surgery. Case 2 had a multilevel macular hemorrhage due to a rupture of a retinal arteriolar macroaneurysm and was treated with pneumatic displacement, laser, and intravitreal ranibizumab. Case 3 presented an extensive subretinal hemorrhage due to a choroidal rupture after high-energy ocular trauma that was also successfully treated with surgery. The last case was a preretinal hemorrhage due to diabetic retinopathy managed with neodymium-doped yttrium aluminum garnet laser. Different treatment approaches were successfully performed in all cases with good outcomes.

Conclusion

There is an extensive range of options available for the management of macular hemorrhages, and the best option depends on the characteristics of each particular case. Proper and timely management of these diseases can achieve an excellent visual outcome, especially if the location of the hemorrhage is preretinal.

Can Baseline Computed Tomography Scans Be Used to Identify Patients at High Risk of Vision Loss due to Terson Syndrome?

PURPOSE

To determine if routinely performed computed tomographic (CT) scanning in patients with aneurysmal subarachnoid hemorrhages (aSAHs) is sufficient to identify patients at high risk of vision loss due to Terson syndrome (TS).

METHODS

Consecutive patients with a diagnosis of aSAH admitted to the neurologic intensive care unit of a regional referral hospital over a 3-year period were prospectively evaluated. Head CT scans performed in the emergency department were assessed for the presence of a "crescent sign" (evidence of significant subinternal limiting membrane hemorrhage). Dilated funduscopic examinations were performed by an ophthalmologist, masked to the results of the CT scan, to identify retinal and vitreous hemorrhages consistent with TS. Retinal hemorrhages were categorized according to size-those smaller than 2 mm in diameter were deemed low risk (lrTS) for vision loss and those larger than 2 mm in diameter were deemed high risk (hrTS) for vision loss.

RESULTS

One hundred seventeen patients with aSAH were enrolled in the study. The overall incidence of TS was 24.9% (29 of 117 patients; 12 were bilateral). Compared to patients without TS, those with TS had a higher Fisher Hemorrhage Grade and a lower mean (±standard deviation) GCS score (8.66 ± 4.97 vs 12.09 ± 1.10; P < 0.001). The CT crescent sign was positive in 7 patients (6.0%), 6 (5.1%; 2 were bilateral) of whom were found to have hrTS. Of the 110 patients without a CT crescent sign, 88 (75.1%) patients did not have TS, 21 had lrTS, and 1 patient had hrTS in one eye. The CT crescent sign was highly sensitive (85.7%) and specific (99.1%) for diagnosing hrTS.

CONCLUSION

The CT crescent sign is a highly sensitive and specific marker for hrTS. CT scanning may replace routine ophthalmologic examinations to identify patients at risk of vision loss due to aSAH.

Microsurgical observation of the posterior vitreous in patients with vitreous hemorrhage caused by Terson syndrome

Purpose

To describe features characteristic of vitreous hemorrhage in patients with Terson syndrome observed through a microsurgical scope.

Methods

Between May 2015 and February 2019, 12 eyes of 10 patients with vitreous hemorrhage occurring after subarachnoid hemorrhage (SAH) underwent pars plana vitrectomy.

Results

During vitreous surgery, we found 10 of 12 eyes did not have posterior vitreous detachment (PVD). Furthermore, we observed in 9 of the 10 eyes without PVD (90.0%) that there was no hemorrhage in the posterior vitreous cavity at the posterior pole while we removed vitreous hemorrhage. We confirmed that this clean space could be the posterior precortical vitreous pocket (PPVP).

Conclusion and importance

Terson syndrome may have no hemorrhage in the PPVP regardless of the presence of severe vitreous hemorrhage. The cases presented in our study may suggest one of the mechanisms of Terson syndrome.

Terson syndrome with persistent vitreous hemorrhage following traumatic brain injury

The objective of this study was to report clinical findings and surgical outcomes of 3 patients with persistent vitreous hemorrhage diagnosed as Terson syndrome (TS). Posterior segment changes, optical coherence tomography scans, fundus autofluorescence images, and fundus fluorescein angiography findings of patients were evaluated and pars plana vitrectomy (PPV) was performed on 3 eyes of three patients. All eyes operated after 6 months from the date of injury and final visual acuities were 20/200, 20/60 and 20/30. PPV is found as a safe and effective procedure for vitreous hemorrhage in TS. Delayed surgery in a young patient predicts a worse outcome.

Clinical features and visual prognostic indicators after vitrectomy for Terson syndrome

PURPOSE

To determine clinical characteristics and identify factors associated with better visual outcomes in patients who had vitrectomy for vitreous haemorrhage (VH) associated with Terson syndrome (TS).

METHODS

The records of 48 patients (54 corresponding eyes) who underwent vitrectomy for VH associated with TS from January 2008 to December 2017 were retrospectively reviewed. The main outcome measure was the final postoperative visual acuity.

RESULTS

At the last visit, 34 eyes (63.0%) achieved a BCVA of 0.3 or better. Eyes associated with traumatic brain injury had a better visual outcome than those with primary intracerebral haemorrhage (P = 0.042). In the primary intracerebral haemorrhage group, patients with hypertension-induced intracranial haemorrhage (IH) showed poorer final visual acuities than the ruptured intracranial aneurysm group (P = 0.023). In the delayed vitrectomy group, epiretinal membrane and peripheral retina changes were more common (P < 0.05). However, the difference in final visual acuity between the early and delayed vitrectomy groups was not significant (P = 0.69).

CONCLUSION

Most of the patients obtained visual recovery after vitrectomy for TS. VH associated with ruptured intracranial aneurysm or traumatic brain injury or eyes without retinal haemorrhage are predictive of better prognosis. Although the timing of vitrectomy was not related to the final postoperative visual outcome, early vitrectomy by three months seems to suggest less epiretinal membrane formation, retinal tears, and retinal detachments.

Pars plana vitrectomy with intraoperative optical coherence tomography for sub-internal limiting membrane fibrosis excision in a child with Terson syndrome: Surgical and pathological correlation

Purpose

To report the intraoperative optical coherence tomography (OCT)-guided surgery of a consolidated sub-internal limiting membrane (ILM) hemorrhage that developed into a sub-ILM fibrotic membrane in a child with a history of Terson syndrome.

Observations

A one year-old boy with a history of Terson syndrome due to a motor vehicle accident presented three months after trauma with a white feather-shaped membrane in the left macula. Preoperative OCT showed a preretinal hyperreflective tissue at the foveal center. The patient underwent pars plana vitrectomy. After separation of the posterior hyaloid, intraoperative OCT did not show any change in structural components. After peeling the ILM, the fibrotic membrane persisted. A bent 30-gauged needle was used to create a plane of dissection in the adherent sub-ILM membrane, which was then peeled with ILM forceps without complication. Post-operative OCT confirmed complete excision without evidence of macular edema. Pathology results indicated presence of fibrocellular tissue that contained hemosiderin, consistent with old organized hemorrhage as a component of the membrane.

Conclusion and importance

Sub-ILM hemorrhage may persist as a tautly adherent fibrotic membrane that can mimic the appearance of an epiretinal membrane or a chronic subhyaloidal hemorrhage during examination, especially in young children. Intraoperative OCT may aid in select complex macular surgery cases to better delineate the planes of dissection during sub-ILM fibrosis excision.

A Case of Terson-Like Syndrome in a Patient with Viral Meningoencephalitis

The proposed mechanism of Terson's syndrome is increased intracranial pressure that leads to dilation of the retrobulbar optic nerve and compression of the central retinal vein. Terson's syndrome has been associated with many conditions that increase intracranial pressure such as venous sinus thrombosis, Moyamoya disease, leukemia, direct head trauma, and intraocular hemorrhage related to shaken baby syndrome. We present a novel case of a patient with recent viral prodrome found to have papilledema and multilayered retinal hemorrhages consistent with Terson syndrome. Computed tomography and magnetic resonance venography of the brain did not reveal any subdural, subarachnoid, or intracranial hemorrhages. However, cerebrospinal fluid analyses were significant for increased opening pressure and elevated protein levels, which were suggestive of viral meningoencephalitis. We describe this case as a Terson-like syndrome because the etiology of intraocular hemorrhage is increased intracranial pressure. However, this case does not fit the traditional presentation of Terson's syndrome as the intracranial pressure is secondary to meningeal inflammation instead of subdural, subarachnoid, or intracranial hemorrhage. We strongly feel that it is important for physicians to be aware of the link between viral meningoencephalitis and retinal conditions such as Terson-like syndrome because it can facilitate rapid diagnosis and treatment.

OUTCOMES OF VITRECTOMY IN TERSON SYNDROME: A Multicenter Canadian Perspective

PURPOSE

To characterize the presentation of Terson syndrome, the occurrence of a vitreous hemorrhage in association with intracranial hemorrhage, and report on the outcomes of vitrectomy at two major centers in Canada.

METHODS

Retrospective chart review of consecutive patients with Terson syndrome undergoing vitrectomy by retina specialists over the last 10 years. Primary outcome was the change in best-corrected visual acuity (BCVA) at 3 months from baseline. Secondary outcomes included the association between baseline BCVA and final BCVA, and the association between final BCVA and timing of surgery (early vs. later than 90 days).

RESULTS

A total of 14 eyes of 11 patients were included. The mean time between observation of intraocular hemorrhage and vitrectomy was 160 days. Baseline preoperative BCVA was logarithm of the minimum angle of resolution 1.57 ± 1.03 (Snellen 20/740), which improved to logarithm of the minimum angle of resolution 0.53 ± 0.82 (Snellen 20/70) at the final postoperative follow-up, P = 0.01. Baseline BCVA was not significantly correlated with final BCVA, Spearman's rho = 0.016, P = 0.957. Final BCVA did not significantly differ between those who had surgery before 90 days compared with after 90 days, P = 0.087.

CONCLUSION

Vitrectomy is safe and effective and should be considered for nonclearing vitreal bleeding due to Terson syndrome. Ocular hemorrhaging in Terson syndrome can be observed conservatively for spontaneous improvement without the risk of reduced visual potential. Ophthalmic evaluation should be considered promptly after intracranial hemorrhage.

Pediatric vitreous hemorrhage: A narrative review

Vitreous hemorrhage is one of the most common causes of sudden, painless loss of vision in adults. This is probably one of the reasons why it has been extensively studied and reported in literature. However, the same cannot be said when it comes to vitreous hemorrhage in the pediatric age group. The causes of vitreous hemorrhage in children tend to differ from those of adults. Not much data exist regarding their presentation and management. In addition to trauma, certain spontaneous causes such as pediatric tumors and congenital conditions assume importance while considering the differential diagnosis of vitreous hemorrhage in the pediatric age group. However, it is natural that the treating ophthalmologist is faced with challenges when a child presents with vitreous hemorrhage. In this narrative review, we have attempted to analyze the retrospective observational studies regarding pediatric vitreous hemorrhage reported in English literature till date. The article sheds some light on the prevailing epidemiology, management strategies employed and the visual outcome among different regions of the world.

Outcomes after Epiretinal Membrane Surgery with or Without Internal Limiting Membrane Peeling

INTRODUCTION

The aim of this study was to assess the incidence of persistent postoperative cystoid macular edema (pCME) in patients undergoing pars plana vitrectomy with epiretinal membrane peel (ERM) only versus those with ERM peel combined with internal limiting membrane peel (ILM). Secondary endpoints of the study were to review both the central macular thickness (CMT) and visual acuity.

METHODS

The patients were divided in two groups, one group in which only the ERM was peeled (n = 36 patients) and another group in which both the ERM and the ILM were removed (n = 62 patients). The results were analyzed retrospectively. Each patient received a complete ophthalmological examination, including best-corrected visual acuity (BCVA) using an ETDRS chart and spectral domain optical coherence tomography, at three time points: prior to surgery and 3 weeks and 3 months after surgery.

RESULTS

A total 98 eyes of 98 patients were included in this study. The mean follow-up time was 7.7 months. CMT decreased significantly after surgery in all patients, and none of these changes differed significantly between the two groups. The BCVA increased significantly after surgery across all patients, and there were no significant changes between the two treatment groups. Postoperative pCME occurred in eight patients in each group, representing 22.2% of the 36 patients in the ERM only group and 12.9% of the 62 patients in the ERM/ILM peel group. However, this difference was not statistically significant.

CONCLUSIONS

No difference was found between the two groups in terms of incidence of pCME. Both groups experienced had similar decrease in the CMT and improvement in the BCVA postoperatively.

Terson Syndrome in a Healthy Term Infant: Delivery-Associated Retinopathy and Intracranial Hemorrhage

A term healthy infant was noted to have cephalohematoma following normal spontaneous vaginal delivery (NSVD). At 9 days of age, the attending team performed wide-angle remote digital fundus imaging and the left eye was noted to have scattered multi-laminar hemorrhages. Magnetic resonance imaging was performed which revealed occipital infarct and subarachnoid hemorrhage. A diagnosis of neonatal Terson syndrome was made. The child remained asymptomatic and the fundus hemorrhages resolved without sequelae. This case represents the first documented instance of Terson syndrome following NSVD and may represent a possible etiology of the common newborn retinal hemorrhage. Alternative terminology - delivery-associated retinopathy and intracranial hemorrhages - is proposed to describe these findings. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e154-e156.].

Terson's Syndrome - case report

Terson's Syndrome is represented by a vitreous, retrohyaloid, retinal, or subretinal hemorrhage occurring consequent to an acute intracranial hemorrhage or elevated intracranial pressure. The outcome may include a complete clearing of the blood and the restoration of VA or persistent hemorrhage. This report presents the case of a 43-year-old woman who underwent bilateral surgery for a persistent vitreous hemorrhage and a hematoma underneath the internal limiting membrane in the left eye. The event followed shortly after a subarachnoid hemorrhage due to the rupture of a posterior communicating artery aneurism. Vitrectomy was performed in both eyes, together with the peeling of the internal limiting membrane in the left eye, followed by a bilateral good outcome.

Bedside optical coherence tomography for Terson's syndrome screening in acute subarachnoid hemorrhage: a pilot study

OBJECTIVE

Approximately 10% of patients with subarachnoid hemorrhage (SAH) become permanently, legally blind. The average cost of lifetime support and unpaid taxes for each blind person amounts to approximately $900,000. This study evaluates the feasibility and potential role of bedside optical coherence tomography (OCT) in Terson’s syndrome (TS) in patients with acute SAH (aSAH) and its potential role in blindness prevention.

METHODS

The authors conducted an open-label pilot study, in which 31 patients with an angiographic diagnosis of aSAH were first screened for TS with dilated funduscopy and then with OCT in the acute phase and at 6-week followup visits. Outpatient mood assessments (Patient Health Questionnaire–depression module, Hamilton Depression Scale), and quality of life general (NIH Patient-Reported Outcomes Measurement Information System) and visual scales (25-item National Eye Institute Visual Functioning Questionnaire) were measured at 1 and 6 weeks after discharge. Exclusion criteria included current or previous history of severe cataracts, severe diabetic retinopathy, severe macular degeneration, or glaucoma.

RESULTS

OCT identified 7 patients with TS, i.e., a 22.6% incidence in our aSAH sample: 7 in the acute phase, including a large retinal detachment that was initially missed by funduscopy and diagnosed by OCT in follow-up clinic. Dilated retinal funduscopy significantly failed to detect TS in 4 (57.1%) of these 7 cases. Intraventricular hemorrhage was significantly more common in TS cases (85.7% vs 25%). None of the participants experienced any complications from OCT examinations. Neither decreased quality of life visual scale scores nor a depressed mood correlated with objective OCT pathological findings at the 6-week follow-up after discharge. There were no significant mood differences between TS cases and controls.

CONCLUSIONS

OCT is the gold standard in retinal disease diagnosis. This pilot study shows that bedside OCT examination is feasible in aSAH. In this series, OCT was a safe procedure that enhanced TS detection by decreasing false-negative/inconclusive funduscopic examinations. It allows early diagnosis of macular holes and severe retinal detachments, which require acute surgical therapy to prevent legal blindness. In addition, OCT aids in ruling out potential false-positive visual deficits in individuals with a depressed mood at follow-up.

25G compared with 20G vitrectomy under Resight non-contact wide-angle lenses for Terson syndrome

The aim of the present study was to compare the effectiveness of 25G vitrectomy to standard 20G vitrectomy for treatment of Terson syndrome under Resight non-contact wide-angle lenses. This was a case-control study of 20 patients with Terson syndrome (study group) that underwent 25G vitrectomy under Resight non-contact wide-angle lenses, with those of 20 matched patients that underwent 20G vitrectomy (control group). Medical records were reviewed from between July 2011 and October 2013. Data included results of the Early Treatment Diabetic Retinopathy Study examination, ophthalmology B-scan ultrasonography and fundus photography. The mean age, follow-up time, the preoperative visual acuity of LogMAR and the preoperative intraocular pressure (IOP) were all comparable in the two groups (all P>0.05). There were statistically significant differences in postoperative visual acuity of LogMAR compared with preoperative visual acuity (P<0.001) in both groups, but no difference between the groups (P=0.845). However, the operative times (13.5 min in study group vs. 42 min in control group) and post-operative IOP at day 1 (13.5 vs. 20 mmHg) were significantly reduced in the study group compared to the control group (P<0.001). Therefore, the present findings suggest that 25G Vitrectomy for Terson syndrome under Resight non-contact wide-angle lenses can achieve a significantly shorter operative time and lower post-operative IOP compared with 20G Vitrectomy.

Visual Outcomes after Vitrectomy for Terson Syndrome Secondary to Traumatic Brain Injury

PURPOSE

To evaluate visual outcomes after vitrectomy for intraocular hemorrhages secondary to traumatic brain injury.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

A total of 28 eyes in 20 patients undergoing vitrectomy for Terson syndrome secondary to traumatic brain injury between 1997 and 2015.

METHODS

We reviewed the records of patients undergoing a standard 20-gauge or 23-gauge pars plana vitrectomy for intraocular hemorrhages secondary to traumatic brain injury, and the timing of vitrectomy in relation to the inciting intracranial event was recorded.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in the preoperative visual acuity score at postoperative month 1 and at the last noted clinic appointment.

RESULTS

A total of 28 eyes in 20 patients (all male) underwent pars plana vitrectomy for intraocular hemorrhages secondary to traumatic brain injury. The mean preoperative baseline logarithm of the minimum angle of resolution (logMAR) (Snellen) best-corrected visual acuity (BCVA) was 1.81±0.56 (20/1290). At 1-month postoperative follow-up, the mean BCVA was 0.30±0.33 (20/40). At the date of the last follow-up, the mean BCVA was 0.15±0.24 (20/30) and the median BCVA was 0.00 (20/20). Although the difference between preoperative and postoperative BVCA was significantly different at 1 month and the final postoperative clinic visits (P < 0.001), there was not a correlation between preoperative visual acuity as a predictor of final postoperative visual acuity outcome (r=-0.32; P = 0.09; 95% confidence interval [CI] -0.62 - 0.06). At the date of the last follow-up, the differences in visual outcomes between the individuals undergoing vitrectomy within 3 months of the inciting event, 0.08±0.15 (20/25), were not significantly different than those undergoing surgical intervention after 3 months, 0.18±0.27 (20/30) (P = 0.28). Three cases among those undergoing vitrectomy after 3 months were complicated by retinal detachment, none of which resulted in a BCVA worse than when the patient originally presented preoperatively.

CONCLUSIONS

In this retrospective series of patients without other ocular pathology, surgical intervention effectively provided rapid visual recovery in the majority of individuals with intraocular hemorrhages secondary to traumatic brain injury, irrespective of the timing of vitrectomy or of preoperative visual acuity.

Terson's syndrome - Pathophysiologic considerations of an underestimated concomitant disease in aneurysmal subarachnoid hemorrhage

Terson syndrome (TS) is a common and underestimated concomitant disease in patients suffering from subarachnoid hemorrhage (SAH). Aim of this study was to evaluate the influence of an initial unconsciousness and raised intracranial pressure (ICP) on the development of TS. We performed a retrospective analysis of 213 prospective collected SAH patients screened for TS to investigate the impact of an initial unconsciousness and raised ICP on the development of TS. A univariate analysis followed by a multivariate logistic regression model was performed to identify risk factors that are associated with TS. The findings are all discussed and correlated with the present pathophysiologic considerations of TS. The rate of TS in this study was 23.9%. A higher risk of TS in the univariate analysis was associated with a Glasgow Coma scale⩽7 (p=0.001), higher Hunt and Hess grade (p=0.001), Fisher grade IV (p=0.002), intracerebral hemorrhage (p=0.011), initial unconsciousness (p=0.013) and an ICP of ⩾25mmHg (p<0.001). An ICP of ⩾25mmHg was the only independent predictor for TS in the multivariate analysis (p=0.007). TS patients had a higher mortality (p=0.012) and a higher risk for a worse long-term outcome (p=0.002). Notable that 5 of 51 TS patients (9.8%) in this study developed TS with no raised ICP or initial unconsciousness. Terson syndrome is a common concomitant disease in SAH patients. The pathomechanism leading to TS is not exclusively related to raised ICP levels and/or unconsciousness. However, these factors may be associated with a high percentage of TS.

Terson syndrome in aneurysmal subarachnoid hemorrhage-its relation to intracranial pressure, admission factors, and clinical outcome

BACKGROUND

A large number of reports have not been able to clarify the pathophysiology of Terson syndrome (TS) in aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Prospective single-center study on aSAH patients. Fundoscopic and radiological signs of TS were assessed. The opening intracranial pressure (ICP) in patients who required a ventriculostomy was recorded with a manometer.

RESULTS

Six out of 36 included patients had TS (16.7 %), which was associated with unfavorable admission scores. Twenty-nine patients (80.5 %) required ventriculostomy; TS was associated with higher ICP (median, 40 vs. 15 cm cmH2O, p = .003); all patients with TS had pathological ICP values of >20 cmH2O. Patients with a ruptured aneurysm of the anterior cerebral artery complex were ten times as likely to suffer from TS (OR 10.0, 95 % CI 1.03-97.50). Detection of TS on CT had a sensitivity of 50 %, a specificity of 98.4 %, a positive predictive value of 83.3 %, and a negative predictive value of 92.4 %. Mortality was 45 times as high in patients with TS (OR 45.0, 95 % CI 3.86-524.7) and neurologic morbidity up until 3 months post-aSAH was significantly higher in patients with TS (mRS 4-6; 100 vs. 17 %; p = .001).

CONCLUSIONS

Our findings demonstrate an association between raised ICP and the incidence of TS. TS should be ruled out in aSAH patients presenting comatose or with raised ICP to ensure upfront ophthalmological follow-up. In alert patients without visual complaints and a TS-negative CT scan, the likelihood for the presence of TS is very low.

Practical Incidence and Risk Factors of Terson's Syndrome: A Retrospective Analysis in 322 Consecutive Patients with Aneurysmal Subarachnoid Hemorrhage

Objective

Terson's syndrome, a complication of visual function, has occasionally been reported in patients with aneurysmal subarachnoid hemorrhage (SAH), however the factors responsible for Terson's syndrome in aneurysmal SAH patients have not yet been fully clarified. In this study, we report on potential risk factors for prediction and diagnosis of Terson's syndrome in the earlier stage of the disease course in patients with aneurysmal SAH.

Materials and Methods

The authors retrospectively analyzed the data of 322 consecutive patients who suffered from aneurysmal SAH in a single institution between Jan. 2007 and Dec. 2013. Medical records including demographics, neurologic examination, and radiologic images were collected to clarify the risk factors of Terson's syndrome. Patients with visual problem were consulted to the Department of Ophthalmology.

Results

Among 332 patients with aneurysmal SAH, 34 patients were diagnosed as Terson's syndrome. Four individual factors, including World Federation of Neurosurgical Societies (WFNS) grade at admission, aneurysm size, method of operation, and Glasgow outcome scale showed statistically significant association with occurrence of Terson's syndrome. Of these, WFNS grade at admission, aneurysm size, and method of operation showed strong association with Terson's syndrome in multivariate analysis. Terson's syndrome accompanied by papilledema due to increased intracranial pressure led to permanent visual complication.

Conclusion

In patients with aneurysmal SAH, the patients' WFNS grade at admission, the size of the aneurysms, particularly the diameter of the aneurysm dome, and the method of operation might influence development of Terson's syndrome.

YAG Laser Membranotomy for Subinternal Limiting Membrane Hemorrhage

PURPOSE

To report the use of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser internal limiting membranotomy to successfully treat the first reported case of subinternal limiting membrane (sub-ILM) hemorrhage that developed after coil embolization of a cerebral aneurysm.

CASE REPORT

A 59-year-old Korean woman visited our clinic complaining of central scotoma in her left eye, which developed shortly after stent-assisted coil embolization of an unruptured internal carotid artery aneurysm. Fundus examination revealed a sub-ILM hemorrhage in her left eye, and after 2 days, a Nd:YAG laser membranotomy was performed with a single 4.5-mJ burst. There was a marked reduction in the sub-ILM hemorrhage 1 day after Nd:YAG laser membranotomy, and after 1 month, her best-corrected visual acuity improved to 20/20, with complete resolution of the sub-ILM hemorrhage.

CONCLUSIONS

Sub-ILM hemorrhage can develop after coil embolization of a cerebral aneurysm, and Nd:YAG laser internal limiting membranotomy can be a useful noninvasive treatment alternative to surgical intervention.

Complications of Macular Peeling

Macular peeling refers to the surgical technique for the removal of preretinal tissue or the internal limiting membrane (ILM) in the macula for several retinal disorders, ranging from epiretinal membranes (primary or secondary to diabetic retinopathy, retinal detachment…) to full-thickness macular holes, macular edema, foveal retinoschisis, and others. The technique has evolved in the last two decades, and the different instrumentations and adjuncts have progressively advanced turning into a safer, easier, and more useful tool for the vitreoretinal surgeon. Here, we describe the main milestones of macular peeling, drawing attention to its associated complications.

Current Trends about Inner Limiting Membrane Peeling in Surgery for Epiretinal Membranes

The inner limiting membrane (ILM) is the basement membrane of the Müller cells and can act as a scaffold for cellular proliferation in the pathophysiology of disorders affecting the vitreomacular interface. The atraumatic removal of the macular ILM has been proposed for treating various forms of tractional maculopathy in particular for macular pucker. In the last decade, the removal of ILM has become a routine practice in the surgery of the epiretinal membranes (ERMs), with good anatomical results. However many recent studies showed that ILM peeling is a procedure that can cause immediate traumatic effects and progressive modification on the underlying inner retinal layers. Moreover, it is unclear whether ILM peeling is helpful to improve vision after surgery for ERM. In this review, we describe the current understanding about ILM peeling and highlight the beneficial and adverse effects associated with this surgical procedure.

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.

Vitreous hemorrhage in pediatric age group

Purpose. To identify and study causes of vitreous hemorrhage (VH) in pediatric age group and to investigate factors predicting visual and anatomical outcomes. Procedure. A retrospective review of patients aged 16 years or less with the diagnosis of vitreous hemorrhage from January 2005 until December 2010. Results. A total number of 230 patients (240 eyes) were identified. Traumatic vitreous hemorrhage accounted for 82.5%. In cases of accidental trauma, final visual acuity of 20/200 was significantly associated with visual acuity of ≥20/200 at presentation and the absence of retinal detachment at last follow-up. Patients with nontraumatic vitreous hemorrhage were significantly younger with higher rates of enucleation/evisceration/exenteration and retinal detachment at last follow-up compared to traumatic cases. Conclusion. Trauma is the most common cause of VH in pediatric age group. In this group, initial visual acuity was the most important predictor for visual outcome, and the presence of retinal detachment is a negative predictor for final good visual outcome. The outcome is significantly worse in nontraumatic cases compared to traumatic cases.

Subarachnoid hemorrhage-negative Terson syndrome after balloon-assisted coil embolization in a patient with underlying antiphospholipid antibody syndrome

PURPOSE

To report subarachnoid hemorrhage-negative Terson syndrome after coil embolization of an unruptured intracranial aneurysm in a patient with underlying antiphospholipid syndrome.

METHODS

Retrospective case report. A 48-year-old woman with underlying antiphospholipid syndrome.

RESULTS

Our patient underwent balloon-assisted coil embolization of an unruptured right internal carotid artery aneurysm. There was herniation of the second coil requiring coil retrieval with subsequent nonflow limiting herniation of the first coil left in situ on anticoagulation. In the immediate postprocedure period, she developed preretinal, intraretinal, and vitreous hemorrhages requiring temporary withholding of anticoagulation therapy with careful resumption. Visual acuity was counting fingers and there was an afferent pupillary defect. Two week after discharge, the patient underwent a pars plana vitrectomy for dense breakthrough vitreous hemorrhage. Four weeks after pars plana vitrectomy, her visual acuity was 20/400.

CONCLUSION

Terson syndrome should be considered in a patient with visual symptoms after not only aneurysmal subarachnoid hemorrhage but also non-subarachnoid hemorrhage elective aneurysm coiling as demonstrated by our case.

Treatment of Valsalva retinopathy

PURPOSE

To report a case of Valsalva retinopathy treated by neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and discuss the previously reported treatments for Valsalva retinopathy.

CASE REPORT

A 35-year-old-woman experienced a sudden painless visual loss in her left eye after lifting heavy bags of manure on the farm. The patient was diagnosed as having Valsalva retinopathy. The examination revealed a macular preretinal hemorrhage. An Nd:YAG laser was used on the patient after conservative management afforded no resolution. After treatment, visual acuity improved.

CONCLUSIONS

Valsalva retinopathy can be treated by conservative management, Nd:YAG laser, and vitrectomy, but each treatment must be evaluated in regard to the duration, the location, and the amount of the hemorrhage.

Intrasurgical imaging of subinternal limiting membrane blood diffusion in terson syndrome

We report a case of Terson syndrome, providing the first intrasurgical imaging of subinternal limiting membrane blood diffusion in Terson syndrome. We highlight some remarkable in vivo anatomical findings that may give a contribution to the debate about its pathogenesis. Here we hypothesize that the subretinal space might be unlikely to be a primary source of intraocular hemorrhage, and we support the two generally accepted theories about blood diffusion from the retinal vasculature or from the perivascular spaces.

Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury

This prospective trial was designed to evaluate the incidence of Terson syndrome in patients suffering from subarachnoid hemorrhage, intracerebral hemorrhage, or traumatic brain injury and whether consequences necessarily derive from the intraocular hemorrhage itself. Two ophthalmologic examinations were performed to identify patients with Terson syndrome. Data on initial Glasgow Coma Scale, Hunt and Hess and Fisher grades, aneurysm site and diameter, and volume of hemorrhage in intracerebral hemorrhage patients were correlated to the location and course of Terson syndrome. Follow-up was performed after 3 months, including clinical and ophthalmologic investigations. The data showed that 16 of 83 subarachnoid hemorrhage patients (19.3%), 2 of 22 intracerebral hemorrhage patients (9.1%), and 1 of 32 traumatic brain injury patients (3.1%) suffered from Terson syndrome. Low Glasgow Coma Scale (p = 0.002), high Hunt and Hess grade (p < 0.001), and high Fisher grade (p = 0.002) were found to be associated with a higher incidence of Terson syndrome. The neurological outcome in subarachnoid hemorrhage patients suffering from Terson syndrome was worse compared with that of subarachnoid hemorrhage patients without Terson syndrome (p = 0.005), and vitrectomy was performed in seven eyes of six patients due to poor visual acuity. Terson syndrome is underestimated in patients with subarachnoid hemorrhage and a rare pathology in intracerebral hemorrhage as well as in traumatic brain injury patients. Spontaneous regression of the intraocular hemorrhage may be seen, but in half of the patients, vitrectomy is necessary to prevent permanent visual deterioration.

[Premacular hemorrhage treatment with Nd:YAG laser: a clinical case]

INTRODUCTION

To report a case of premacular hemorrhage treated with Neodymium (Nd):YAG laser puncture.

CASE REPORT

A 54 year-old Caucasian female was seen in the emergency department with complaints of sudden loss of vision in her right eye (RE), detected on the previous day. The best-corrected visual acuity (BCVA) in the RE was reduced to light perception, and fundoscopy evidenced a large and dense premacular hemorrhage. An Nd:YAG laser puncture was performed that day to drain the hemorrhage into the vitreous cavity. The intravitreal hemorrhage cleared in about 1 month, and the BCVA of the RE was 20/25 after 3 months.