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Terson Syndrome

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Title: Terson Syndrome
Author (s): Dan Nguyen, MS4
Photographer: Unknown
Date: 8/16/17
Keywords/Main Subjects: Terson Syndrome, boat hemorrhage
Diagnosis: Terson Syndrome
Description of Case: Terson Syndrome is intraocular hemorrhage (IOH) in the presence of intracranial hemorrhage or elevated intracranial pressure (ICP). IOH can include vitreous, sub-hyaloid, pre-retinal, intraretinal, and subretinal bleeding. Vitreous hemorrhage is the most frequent subtype of ocular hemorrhage in Terson syndrome. It may present with visual loss and can cause permanent blindness if severe. It is most commonly associated with subarachnoid hemorrhage (SAH) secondary to an anterior circulation aneurysmal rupture. It can be seen in up to 46% of SAH patients, and its presence is associated with a higher mortality in SAH. The sudden spike in ICP with aneurysmal rupture is thought to underlie the cause of IOH. This increased pressure is transmitted along the optic nerve sheath and causes sudden intraocular venous HTN and rupture of thin capillary walls. The diagnosis is made with a fundoscopic exam, and ophthalmological exams should be routinely performed in patients diagnosed with SAH. Related complications of Terson Syndrome include macular holes, epiretinal membrane formation, proliferative vitreoretinopathy, retinal folds, retinal detachments, and optic neuropathy.

Some recommendations in literature suggest 3-6 months of observation after the acute event followed by vitrectomy if there is no improvement in visual acuity. But other studies suggest that earlier intervention before 3 months is optimal, especially in younger patients.

The fundus photos are from patient TS, a 35 year old female who was seen at Moran emergently for papilledema. Previously, she was found to have a Chiari malformation and had a suboccipital craniectomy at the end of May. On 7/29 she woke up on the floor, unable to move for 25 minutes, and had bilateral vision loss and was only able to see colors and shapes. At Moran she was noted to have stage III papilledema and peripapillary hemorrhages and was sent to the University ED. She had an LP with an opening pressure of 35 cm and was admitted to Neurosurgery with a shunt placed on 7/31. She was seen in the Neuro-Ophthalmology clinic on 8/16 with continued vision impairment, particularly in her right eye. On exam, her VA was 20/200 OD and 20/25 OS with correction. She had a tilt afferent pupillary defect OD. Slit lamp showed vitreous RBCs bilaterally, OD > OS. Fundoscopic exam (see pictures below) showed large pre-retinal/subhyaloid hemorrhages OU, more central OD vs OS. Visual fields showed mild central scotoma OD. The etiology of her ICP elevation is uncertain. She was treated with a pars plana vitrectomy (PPV) with membrane peeling (MP) in her right eye. Following surgery her VA improved to 20/30 post-op day 1.

Images or video:

Fundoscopic photograph demonstrating boat shaped retinal heme in the right eye of patient TS due to Terson Syndrome. In this specific case, the heme is a result of pre-retinal hemorrhage, posterior to the internal limiting membrane and anterior to the nerve fiber layer. Sub-hyaloid hemorrhage, a result of heme between the posterior vitreous base and the internal limiting membrane, presents similarly as a boat shaped retinal heme. The only way to reliably differentiate between sub-hyaloid and pre-retinal heme is during surgery.

Fundoscopic photograph demonstrating boat shaped heme in OS of patient TS from either sub-hyaloid or pre-retinal hemorrhage. Here, the macula is less affected vs OD, and this is seen clinically with her VA, 20/200 OD and 20/25 OS.

 Summary of the Case: TS is a 35 YO F who presents with decreased vision secondary to pre-retinal hemorrhage due to transient elevated ICP resulting in intra-ocular hemorrhage. Intra-ocular hemorrhage subsequent to intracranial hemorrhages or elevated IOP is known as Terson Syndrome. The patient was treated with PPV with MP and her vision OD improved from 20/200 pre-surgery to 20/30 post-surgery.

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  1. Hassan, A. Giuseppe, L. Eelco, FM et al. Terson’s Syndrome. Neurocrit Care. 2011 May;15:554-558.
  2. Fang, K. Knox, DL. The Ocular Pathology of Terson’s Syndrome. American Academy of Ophthalmology. 2010;117:1423-1429.
  3. Garweg, JG. Koerner, F. Outcome Indicators for Vitrectomy in Terson Syndrome. Acta Ophthalmologica. 2009;87:222-226.

Faculty Approval by: Paul Berstein, MD

Copyright statement: Copyright Dan Nguyen, ©2015. For further information regarding the rights to this collection, please visit:
Identifier: Moran_CORE_24577