Traumatic terson syndrome with a peculiar mass lesion and tractional retinal detachment: a case report

BACKGROUND

To report a case with bilateral Terson syndrome presented with a unique mushroom-like mass lesion on the optic disc along with proliferative vitreoretinopathy and tractional retinal detachment.

CASE PRESENTATION

A 33-year-old man was injured during a traffic accident and had diffuse brain swelling and intraocular hemorrhage. Poor vision in both eyes was noted after the patient regained consciousness. B-scan ultrasonography showed extensive vitreous opacity with a posterior vitreous detachment and without obvious retinal detachment. Vitrectomy was performed in both eyes five months after the accident. After clearing up the vitreous opacity, a peculiar pigmented mushroom-like mass lesion was noted in the posterior pole and had severe adhesion to the underneath optic disc. Extensive multilayered peripapillary epiretinal membrane was found covering the posterior pole and led to tractional retinal detachment around the macula. The mass was presumed to be an organized vitreous hemorrhage originated from the optic disc. The extensive and adherent epiretinal membrane together with the mass lesion were removed as much as possible and silicon oil was injected for tamponade. However, in the right eye, the retina redetached under silicon oil, whereas in the left eye, his vision improved to 20/100.

CONCLUSIONS

Terson syndrome usually has a favorable prognosis but may be complicated by proliferative vitreoretinopathy and tractional retinal detachment. Careful monitoring is warranted and early vitrectomy should be considered in cases suspecting additional pathologies.

Acute bilateral vision loss after endovascular treatment of an intracranial aneurysm

Acute bilateral vision loss (ABVL) is a rare and challenging diagnostic issue that is most often caused by a neurological disorder. Since it can be the presenting symptom of potentially life-threatening diseases, priority should be given to excluding such diagnoses. Special caution is required if ABVL symptoms result after an intracranial intervention. This article reports on a diagnostic approach for a patient suffering from ABVL due to vitreous hemorrhage related to a subarachnoid hemorrhage (SAH) after endovascular intracranial aneurysm treatment. This case study highlights the importance of imaging interpretation and its consequences.

Delayed macular hole secondary to Terson syndrome: a case report and literature review

Terson syndrome refers to intraocular haemorrhage that occurs due to subarachnoid bleeding associated with an acute increase in intracranial pressure. No previous study has reported a delayed macular hole (MH) secondary to Terson syndrome. A 17-year-old boy visited our department and presented with vitreous bleeding and a history of subarachnoid haemorrhage. Sub-internal limiting membrane (ILM) haemorrhage with ILM detachment and intraretinal haemorrhage were detected during pars plana vitrectomy. Additionally, a delayed MH was detected 1 week after the surgery. There was no sign of MH closure during a 2-month follow-up. Subsequently, an MH massage was performed to close the MH. Our findings suggest that a delayed MH can occur secondary to Terson syndrome. Elevated hydrodynamic pressure and hydrostatic pressure, which are caused by sub-ILM and intraretinal haemorrhages of the fovea, contribute to the formation of an MH. Additionally, ILM peeling may cause damage to the macula and facilitate the formation of MHs. Although the MH may close by itself, early surgical intervention is recommended when there is no sign that the MH will close spontaneously because a prolonged MH can lead to retinal damage.

[Terson syndrome and acute myeloid leukemia (case report)]

The article presents a clinical case of bilateral Terson syndrome caused by the manifestation of acute myeloid leukemia. A 32-year-old man complained of a sharp decrease in vision in both eyes. Spontaneous subarachnoid hemorrhage occurred secondary to acute myeloid leukemia. Uncorrected visual acuity (UCVA) amounted to OD=0.01, OS=0.005. The anterior segment was normal in both eyes, voluminous immobile white-gray mass measuring 7-9 DD that completely covered the macula (intense hyperechoic cell suspension with a volume of about 1/2 of the vitreous cavity, ultrasound B-scan) were visualized in the posterior pole of the vitreous body of both eyes under conditions of maximum drug-induced mydriasis. Diagnosis: vitreous hemorrhage due to subarachnoid hemorrhage in both eyes secondary to acute myeloid leukemia. Vitrectomy was performed in both eyes. UCVA increased to 0.05 in both eyes. Vitrectomy contributed to improvement of visual functions and patient quality of life.

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience

BACKGROUND

Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept.

METHODS

All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05.

RESULTS

A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001).

CONCLUSIONS

TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Terson syndrome secondary to aneurysmal subarachnoid hemorrhage in a child: illustrative case

BACKGROUND

Terson syndrome is the phenomenon of intraocular hemorrhage in the setting of subarachnoid hemorrhage (SAH). Vision loss can lead to morbidity for the affected individual. Aneurysmal SAH related to intracranial aneurysms is rare in children. Studies have shown the incidence of Terson syndrome in adults with aneurysmal SAH to be over 40%; however, few cases of Terson syndrome in pediatric aneurysmal SAH have been reported.

OBSERVATIONS

A 9-year-old male presented with altered mental status and seizures. Computed tomographic angiography showed aneurysmal SAH from a ruptured, left-sided posterior inferior cerebellar artery aneurysm. The patient underwent endovascular treatment with coiling and external ventricular drainage for SAH. Ophthalmological consultation for blurry vision revealed the diagnosis of Terson syndrome with decreased vision in the left eye, which was managed conservatively.

LESSONS

Terson syndrome after SAH can occur in children. Prompt ophthalmological evaluation in pediatric patients with aneurysmal SAH is vital for recognition and management to decrease overall morbidity.

Terson Syndrome: Not to Be Missed in Patients with Disorders of Consciousness

The diagnosis of clinical cognitive motor dissociation (^cCMD) can be hindered by pitfalls during standardized clinical evaluation based on gold-standard neurobehavioral rating scales. We introduce here a new pitfall, by reporting two cases of Terson syndrome (TS) after subarachnoid haemorrhage (SAH) caused by the rupture of an anterior communicant artery aneurysm, hospitalized in the Acute Neurorehabilitation Unit (ANR) of CHUV. TS is reported to occur in 8-19.3% of patients suffering from SAH. It can lead to significant visual impairment and if unrecognized, may impair the patient's capacity to interact appropriately with the environment; it thus presents an important pitfall in recognizing clinical cognitive-motor dissociation (^cCMD) in patients with altered states of consciousness. An early ophthalmological exam should be considered in all patients with SAH and disorders of consciousness or visual complaints.

Anatomical and surgical considerations and outcomes in infantile Terson syndrome

Purpose

To study the presentation and outcomes of infantile Terson syndrome (TS).

Methods

This was a retrospective analysis of 18 eyes of nine infants diagnosed to have TS-related intraocular hemorrhage (IOH).

Results

Nine infants (seven males) were diagnosed to have IOH secondary to TS, of which eight infants had imaging features suggestive of intracranial bleed meeting our definite criteria. Median age at presentation was 5 months. In 11 eyes of six infants with suspected birth trauma, the median age of presentation was 4.5 months (range 1-5 months) of which one baby had a history of suction cup-aided delivery and four babies had a history of seizures. Vitreous hemorrhage (VH) was noted in 15 eyes (extensive in 11 eyes). Ten of these eyes showed membranous vitreous echoes, or triangular hyperechoic space with apex at the optic nerve head (ONH) posteriorly and base at the posterior lens capsule anteriorly, with or without dot echoes in the rest of the vitreous cavity, with a configuration of "tornado-like hemorrhage" suggestive of Cloquet's canal hemorrhage (CCH). Eight eyes underwent lens-sparing vitrectomy (LSV) and one eye underwent lensectomy with vitrectomy (LV). On follow-up, disc pallor and retinal atrophy were noted in 11 and 10 eyes, respectively. The mean follow-up was 62 months (1.5 month-16 years). Visual acuity/behavior improved in all cases at the final follow-up. Developmental delay was noted in four children.

Conclusion

Unexplained and altered vitreous hemorrhage with typical ultrasonography (USG) features should raise the suspicion of CCH in TS. Despite early intervention to clear visual axis, anatomical and visual behavior may remain subnormal.

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.

Pathogenesis of Terson syndrome

Purpose

The aim of this experimental study was to investigate the pathogenesis of Terson syndrome (TS), which currently is controversial.

Methods

The central retinal artery (in 39 orbits), posterior ciliary arteries (in 8 orbits), and central retinal vein (CRV in 21 orbits) were occluded in rhesus monkeys by exposing them to lateral orbitotomy. Fundus examination and fluorescein fundus angiography were performed before and immediately after cutting the vessels and serially thereafter during the follow-up period. The rationale of the experimental study design is discussed.

Results

In eyes with central retinal artery occlusion, retinal hemorrhages were seen soon after the procedure in 7 eyes, and on follow-up in a total of 15 eyes. In posterior ciliary artery occlusion, retinal hemorrhages were seen soon after the procedure in one eye, and on follow-up in a total of three eyes. In eyes with CRV, all eyes had extensive scattered retinal hemorrhages.

Conclusion

The findings of this experimental study, and my basic, experimental, and comprehensive clinical studies on CRVO, suggest the following concept of the pathogenesis of TS: Compression of the CRV plays a crucial role in the development of TS. The CRV is compressed, as it lies in the subarachnoid space of the optic nerve sheath, by raised cerebrospinal fluid pressure and/or accumulated blood.

. This results in retinal

venous stasis and raised venous pressure in the retinal veins, leading to venous engorgement, rupture of the retinal capillaries.

and

retinal hemorrhages. The clinical importance of compression of the CRV and not occlusion of CRV in TS is that optic nerve sheath decompression by opening it and releasing the blood and raised cerebrospinal fluid (CSF) pressure, would result in immediate decompressing of the CRV in the subarachnoid space and restoration of normal circulation and prevent visual loss.

Ultrasound diagnosis of Terson syndrome as an indicator of extreme severity in neurocritical care patients

INTRODUCTION

Terson syndrome (TS) is defined as any intraocular haemorrhage identified in patients with acute intracranial pathology. TS appears to be associated with clinical severity in patients with subarachnoid haemorrhage (SAH), but the association is yet to be defined in patients with traumatic brain injury (TBI) and intracerebral haemorrhage (ICH). This study aimed to evaluate the diagnostic performance of ocular ultrasound (OU) and its usefulness in clinical practice.

MATERIAL AND METHODS

We performed an observational, prospective, single-centre study of neurocritical care patients. We analysed cases and controls, defined according to indirect ophthalmoscopy (IO) and OU findings. We determined the diagnostic characteristics of OU. A multivariate analysis was performed to identify clinically relevant associations.

RESULTS

The sample included 91 patients diagnosed with ICH (41.76%), SAH (29.67%), and TBI (28.57%). TS was identified by OU in 8 patients (8.79%) and by IO in 24 (24.37%). The adjusted mortality rate in patients with TS showed an odds ratio (OR) of 4.15 (95% confidence interval [CI], 1.52-11.33). All patients with TS detected by OU presented Glasgow Coma Scale scores < 9, with an elevated risk of needing decompressive craniectomy (OR: 9.84; 95% CI, 1.64-59). OU presented an overall sensitivity of 30.43%, specificity of 98.53%, and diagnostic accuracy of 81.32%. For the detection of vitreous haemorrhage, sensitivity and specificity were 87.5% and 98.5%, respectively.

CONCLUSIONS

OU diagnosis of TS identifies extremely critical patients, who may require the highest level of care; TS is an independent risk factor for in-hospital mortality.

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.

•

The etiopathogenesis of TS has been controversial since its appearance.

•

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

•

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

•

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

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.

Ocular Fundus Abnormalities in Acute Subarachnoid Hemorrhage: The FOTO-ICU Study

BACKGROUND

Ocular fundus abnormalities, especially intraocular hemorrhage, may represent a clinically useful prognostic marker in patients with acute subarachnoid hemorrhage (SAH).

OBJECTIVE

To evaluate associations between ocular fundus abnormalities and clinical outcomes in acute SAH.

METHODS

Prospective evaluation of acute SAH patients with ocular fundus photography at bedside. Multivariable logistic models were used to evaluate associations between fundus abnormalities and poor outcome (inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4) and intensive care unit (ICU) and hospital lengths-of-stay, controlling for APACHE II score, respiratory failure at ICU admission, Hunt & Hess score, aneurysmal etiology, age, and sex.

RESULTS

Fundus abnormalities were present in 29/79 patients with acute SAH (35.4%), and 20/79 (25.3%) had intraocular hemorrhage. In univariate analyses, poor outcomes were more likely among patients with fundus abnormalities vs without (15/28 [53.6%] vs 15/51 [29.4%], P = .03); median length of ICU stay was longer in patients with intraocular hemorrhage than without (18 d [interquartile range (IQR) 12-25] vs 11 [IQR 7-17], P = .03). Logistic regression with fundus abnormality as predictor of interest showed that male sex (odds ratio [OR] 5.33 [95% CI 1.09-26.0], P = .045), higher APACHE II (OR, per 1-point increase, 1.35 [95% CI 1.08-1.78], P = .01), and aneurysmal etiology (OR 4.35 [95% CI 1.01-22.9], P = .048), but not fundus abnormalities (OR 1.56 [95% CI 0.43-5.65], P = .49) or intraocular hemorrhage (OR 1.28 [95% CI 0.26-5.59], P = .75) were associated with poor outcome.

CONCLUSION

Although ocular fundus abnormalities are associated with disease severity in SAH, they do not add value to patients' acute management beyond other risk factors already in use.

Pseudotumor cerebri syndrome causing a terson like syndrome

Purpose

Terson syndrome presents with retinal and vitreous hemorrhages in patients with a subarachnoid hemorrhage or after acutely elevated intracranial pressure. The source of this hemorrhage has been debated and may originate either from direct extension of intracranial hemorrhage or more likely from the peripapillary retinal vessels.

Observations

A 39-year-old woman presenting with nausea, vomiting, floaters and papilledema with normal neuroimaging was diagnosed ultimately with pseudotumor cerebri syndrome. She had a right vitreous hemorrhage and bilateral subretinal and intraretinal hemorrhages which were consistent with Terson like syndrome. Her symptoms resolved with acetazolamide over one month and the retinal and vitreous hemorrhages significantly improved over two months.

Conclusions and importance

This case with initial presentation of pseudotumor cerebri syndrome causing a Terson like syndrome may help elucidate the mechanism behind the etiology of these hemorrhages from leaking peripapillary vessels.

Ultrasound diagnosis of Terson syndrome as an indicator of extreme severity in neurocritical care patients

INTRODUCTION

Terson syndrome (TS) is defined as any intraocular haemorrhage identified in patients with acute intracranial pathology. TS appears to be associated with clinical severity in patients with subarachnoid haemorrhage (SAH), but the association is yet to be defined in patients with traumatic brain injury (TBI) and intracerebral haemorrhage (ICH). This study aimed to evaluate the diagnostic performance of ocular ultrasound (OU) and its usefulness in clinical practice.

MATERIAL AND METHODS

We performed an observational, prospective, single-centre study of neurocritical care patients. We analysed cases and controls, defined according to indirect ophthalmoscopy (IO) and OU findings. We determined the diagnostic characteristics of OU. A multivariate analysis was performed to identify clinically relevant associations.

RESULTS

The sample included 91 patients diagnosed with ICH (41.76%), SAH (29.67%), and TBI (28.57%). TS was identified by OU in 8 patients (8.79%) and by IO in 24 (24.37%). The adjusted mortality rate in patients with TS showed an odds ratio (OR) of 4.15 (95% confidence interval [CI], 1.52-11.33). All patients with TS detected by OU presented Glasgow Coma Scale scores < 9, with an elevated risk of needing decompressive craniectomy (OR: 9.84; 95% CI, 1.64-59). OU presented an overall sensitivity of 30.43%, specificity of 98.53%, and diagnostic accuracy of 81.32%. For the detection of vitreous haemorrhage, sensitivity and specificity were 87.5% and 98.5%, respectively.

CONCLUSIONS

OU diagnosis of TS identifies extremely critical patients, who may require the highest level of care; TS is an independent risk factor for in-hospital mortality.

Vitelliform Vitreoretinopathy: Clinical Implications of the Vitreomacular Interface

Pathologies of the vitreomacular interface are implicated in a variety of sight-threatening clinical entities. The authors present a photo essay of a case of Terson syndrome with a striking premacular dehemoglobinized hemorrhage with ovoid morphology. This unique “vitelliform” finding highlights the distinct structure of the premacular vitreous space and its important implications in both health and disease.

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.

Clinical characteristics of asymptomatic Terson syndrome in the patients with aneurysmal subarachnoid hemorrhage

AIM

To investigate clinical characteristics of asymptomatic Terson syndrome and its clinical impact in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

This retrospective, interventional study included 31 patients with aneurysmal SAH, and the medical records were reviewed. In addition to baseline characteristics of the study population such as age, sex, and underlying medical history, multi-modal imaging analysis, including fluorescein angiography (FA), spectral domain optical coherence tomography (SD-OCT), were also reviewed. Glasgow Coma Scale (GCS), Hunt-Hess (HH) grade, and Fisher scale at the time of admission, and functional outcome by using modified Rankin Scale (mRS) at 6mo were compared.

RESULTS

Of the 31 patients, 10 patients (32.3%) were diagnosed with Terson syndrome. All the patients with Terson syndrome did not report visual symptoms at the time of ophthalmologic screening. FA showed microvascular changes of retinal capillaries and varying degrees of disc leakage. SD-OCT allowed intuitive anatomical localization of multi-layered retinal hemorrhages and assessment of ellipsoid zone integrity. The patients with Terson syndrome showed significantly worse GCS (P=0.047) and HH grade (P=0.025) than those without, except Ficher scale (P=0.385). There was no significant difference in the mRS (P=0.250) at 6mo. Among baseline factors, the HH grade was the only significant factor associated with Terson syndrome (B=1.079, P=0.016).

CONCLUSION

In our study, 32.3% of the patients have Terson syndrome without visual symptoms. The baseline HH grade is significantly correlated with Terson syndrome, and there is no significant difference in the functional outcome between the patients with and without Terson syndrome. Terson syndrome may develop without any visual symptoms as shown in our study, and ophthalmologic screening may be recommended to prevent further visual deterioration especially in the patients with poor HH grade at the time of aneurysmal SAH.

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.

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.

Terson syndrome secondary to subarachnoid hemorrhage: a case report and literature review

BACKGROUND

Terson syndrome is a serious complication of subarachnoid hemorrhage includes any intraocular hemorrhage and may result in blurred vision or even blindness. However, it is often overlooked clinically.

CASE DESCRIPTION

A 42-year-old man presented with coma due to rupture of a left posterior communicating artery aneurysm. A preoperative CT scan demonstrated subarachnoid hemorrhage (SAH) and bilateral fundus hemorrhage. Visual evoked potential (VEP) and B-scan ocular ultrasound revealed vitreous hemorrhages, features consistent with Terson syndrome. Pars plana vitrectomy was performed 2 weeks after SAH with a subsequent improvement of visual acuity.

CONCLUSIONS

Early identification is important for the recovery of the patient's nervous system and ophthalmology. Neurosurgeons should be aware of the pathology and pay attention to it to maximize patient's benefit.

Sub-inner limiting membrane hemorrhage in a patient with Terson syndrome

PURPOSE

To report a case of bilateral Terson Syndrome with sub inner limiting membrane hemorrhage associated with a rare finding: perimacular fold.

METHODS

The patient, a 34 years old female with aneurysmal subarachnoid hemorrhage and bilateral Terson syndrome was admitted to the Ophthalmology department, complaining of blurred vision. Core vitrectomy, hyaloid detachment, peeling of the ILM and aspiration of the sub inner limiting membrane hemorrhage was performed. Once the inner limiting membrane of the left eye was peeled off, we noticed a particular aspect: the perimacular fold.

RESULT

Although our patient suffered from a massive vitreous haemorrhage the postoperative outcome was favorable with a final best corrected visual acuity of 20/30.

CONCLUSIONS

In patients with billateral Terson syndrome we recommend early surgery, especially if the neurological status allows it, a good visual acuity being helpful for the neurophysical rehabilitation of the patient.

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.

Carotid cavernous fistula with central retinal artery occlusion and Terson syndrome after mid-facial trauma

Objectives: To report a rare occurrence combination of central retinal artery occlusion (CRAO) and Terson syndrome in a Barrow's type A carotid cavernous fistula (CCF) patient. Methods: Observational case report. Results: A twenty-year-old male patient with a history of road traffic accident presented with periorbital swelling and redness in the left eye. Examination revealed a CRAO with intraretinal and preretinal hemorrhages. On imaging, type A CCF and subarachnoid hemorrhage were detected. He underwent embolization of the fistula for cosmetic blemish. The possible mechanisms and clinical implications are discussed. Conclusion: Patients with a head injury can have serious ocular damage. Posterior segment manifestations of CCFs are varied and at times can occur in various rare combinations, making it challenging. Early recognition of these rare manifestations and a multi-disciplinary approach are needed in patients with head trauma.

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.

[Retinal bleeding and venous stasis in a 10-month-old infant after a fall?]

This report describes the case of a 10-month-old infant, who was delivered to our hospital by the emergency physician intubated and in an unclear unconscious state. The father reported that the child had fallen from the couch to the ground. The consulted ophthalmologist reported venous stasis in both eyes including intraretinal and preretinal bleeding in all four quadrants, a diffuse vitreous hemorrhage in the right eye and temporal retinal wrinkling in both eyes. Based on these particular clinical findings a shaken baby syndrome was suspected. This report demonstrates the importance of recognizing and correctly interpreting the typical ophthalmological signs of physical child abuse in order to detect and prevent further mistreatment of children; moreover, the increasing importance of photographic documentation and histological work-up of the findings for forensic reasons are emphasized.

Terson Syndrome in Aneurysmal Subarachnoid Hemorrhage: A Case Report

Terson syndrome refers to oculocerebral syndrome of retinal and vitreous hemorrhage associated with spontaneous subarachnoid hemorrhage or all forms of intracranial bleeding. Recent observations have indicated that patients with spontaneous subarachnoid hemorrhage have an 18% to 20% concurrent incidence of retinal and vitreous hemorrhages with about 4% incidence of vitreous hemorrhage alone. Clinical ophthalmologic findings may have significant diagnostic and prognostic value for clinicians. Here we report a 45-year-old female patient who suffered from blurred vision after subarachnoid hemorrhage. She was diagnosed as Terson syndrome. After vitrectomy, she recovered with normal visual acuity which facilitated the rehabilitative process. We also performed visual evoked potentials to investigate abnormalities of visual dysfunction. Based on this case, we emphasize the importance of early diagnosis of Terson syndrome.

Early Intraocular Complications of Subarachnoid Haemorrhage after Aneurysm Rupture

The aim of this study was to identify factors predisposing for early intraocular complications of aneurysmal subarachnoid haemorrhage (SAH). The authors analysed 96 selected cases of aneurysmal SAH. Forty patients (42%) demonstrated abnormal fundus findings, including disc swelling (13.5%), retinal haemorrhages (23%), and vitreous haemorrhage (5%). The incidence of intraocular pathologies was significantly higher in patients who lost consciousness at the onset of SAH, were admitted with high scores of the Hunt-Hess and Fisher scales and low score of the Glasgow Coma Scale, as well as in those with arterial hypertension, more sizable aneurysm, and older.

Terson syndrome with no cerebral hemorrhage: A case report

The present study reports the case of a 33-year-old male who presented with Terson syndrome with no cerebral hemorrhage secondary to traumatic brain injury (TBI). A computed tomography scan of the patient, who had sustained an impact injury to the right occipital region, showed no cerebral lesion. Ophthalmoscopy clearly demonstrated vitreous hemorrhage in both eye globes. Vitreous hemorrhage, which results from an abrupt increase in intracranial pressure (ICP), is associated with TBI. In this case, the visual disturbance was attributed to Terson syndrome secondary to TBI. Therefore, close ophthalmological and radiological evaluation is required in patients with TBI, in order to enable the diagnosis of Terson syndrome and an early vitrectomy.

Terson syndrome caused by intraventricular hemorrhage associated with moyamoya disease

Terson syndrome was originally used to describe a vitreous hemorrhage arising from aneurysmal subrarachnoid hemorrhage. Terson syndrome can be caused by intracranial hemorrhage, subdural or epidural hematoma and severe brain injury but is extremely rare in intraventricular hemorrhage associated with moyamoya disease. A 41-year-old man presented with left visual disturbance. He had a history of intraventicular hemorrhage associated with moyamoya disease three months prior to admission. At that time he was in comatose mentality. Ophthalmologic examination at our hospital detected a vitreous hemorrhage in his left eye, with right eye remaining normal. Vitrectomy with epiretinal membrane removal was performed. After operation his left visual acuity was recovered. Careful ophthalmologic examination is mandatory in patients with hemorrhagic moyamoya disease.