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.

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

The Neuro-ophthalmic Presentation of Intracranial Aneurysms

PURPOSE: To investigate the neuro-ophthalmic diagnosis and clinical manifestations of intracranial aneurysm. METHODS: A retrospective survey of 33 patients who were diagnosed with intracranial aneurysm and underwent neuro-ophthalmic examination from April 2008 to December 2016. Frequency of the first diagnosis of intracranial aneurysm in ophthalmology, neuro-ophthalmic diagnosis, location of intracranial aneurysm, examination of intracranial aneurysm rupture, and neurologic prognosis of Terson's syndrome patients were analyzed by image examination, neurosurgery, and ophthalmology chart review. RESULTS: Of the 33 patients, most patients (n = 31, 94%) were diagnosed with intracranial aneurysm at the neurosurgical department and only 2 patients were diagnosed initially at the ophthalmology department. Causes and association were: Terson's syndrome (n = 10, 30%), third cranial nerve palsy (n = 10, 30%), internclear ophthalmoplegia (n = 4, 12%), visual field defect (n = 3, 9%), optic atrophy (n = 3, 9%), sixth cranial nerve palsy (n = 2, 6%), and nystagmus (n = 1, 3%). The location of intracranial aneurysms were: anterior communicating artery (n = 13, 39%), medial communicating artery (n = 12, 36%), and posterior communicating artery (n = 5, 15%). Ten of 33 patients had Terson's syndrome, and 6 patients (60%) with Terson's syndrome had apermanent neurological disorder such as agnosia, gait disorder and conduct disorder. CONCLUSIONS: Third cranial nerve palsy was the most common neuro-ophthalmic disease in patients presenting with intracranial aneurysm. The neuro-ophthalmic prognoses for those diseases were relatively good, but, if Terson's syndrome was present, neurological disorders (agnosia, gait disorder, conduct disorder) were more likely to remain after treatment.

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.

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.

A Case of Arachnoid Cyst With Floater Symptom

PURPOSE: To report a case of a 9-year-old girl who complained of a floater symptom due to preretinal hemorrhage, subdural hemorrhage and arachnoid cyst. CASE SUMMARY: A 9-year-old girl presented to our clinic with floater symptom in her right eye and a headache. Her corrected visual acuities were 20/20 in both eyes. Preretinal hemorrhage around the optic disc in both eyes was observed. Brain MRI revealed subdural hemorrhage on the frontal, temporal, and parietal lobes, and the arachnoid cyst in the right fronto-temporal lobe. One year later, the preretinal hemorrhages were absorbed. CONCLUSIONS: Arare case of concomitant preretinal and spontaneous subdural hemorrhage with arachnoid cyst was presented. The utilization of brain MRI is recommended to determine underlying causes when fundus examination reaveals retinal hemorrhage without trauma, systemic disease and neurologic symptom.

Macular Pseudohypopyon in Bilateral Terson's Syndrome

PURPOSE: To report a case of a macular pseudohypopyon in the right eye in bilateral Terson's syndrome. CASE SUMMARY: During a right eye vitrectomy of a 56-year-old female patient who showed bilateral Terson's syndrome with subarachnoid hemorrhage, a macular pseudohypopyon was observed. In an oval-shaped subinternal limiting membrane cyst (4x2 diameter size disc) including the central fovea, white exudates with fluid levels were present. The macular pseudohypopyon in the right eye was suspected to have occurred during the absorption of the subinternal limiting membrane hemorrhage. In the left eye, white exudates were clustered in the central fovea. In the right eye, the central fovea was above the fluid level of the pseudohypopyon, and corrected visual acuity was 1.0 after 6 months. Two months after the operation, the pseudohypopyon was absorbed.

Full Thickness Macular Holes Associated with Terson Syndrome

PURPOSE: To report a case of a full-thickness macular hole caused by Terson syndrome. CASE SUMMARY: A 49-year-old man presented to our clinic with decreased visual acuity in the right eye after a subarachnoid hemorrhage due to spontaneous rupture a middle cerebral artery aneurysm. On the first examination, the corrected visual acuity was hand movement in the right eye and 1.0 in the left eye. There was massive vitreous hemorrhage in the right eye. In the left eye, there was no abnormal ocular finding. He was diagnosed with vitreous hemorrhage due to Terson syndrome and waited for the spontaneous absorption of the vitreous hemorrhage. Six months later, the vitreous hemorrhage was considerably absorbed, but a macular hole was observed. OCT scans showed a full-thickness macular hole with an epiretinal membrane.

Postoperative Visual Recovery and Complications of Vitrectomy in Terson's Syndrome

PURPOSE: To investigate the visual recovery and complications of vitrectomy in Terson's syndrome. METHODS: A retrospective study was carried out on 11 eyes in 9 patients who had undergone pars plana vitrectomy for Terson's syndrome from October 2004 to June 2006. The factors assessed were age, gender, presence of hypertension, type of intracranial hemorrhage, preoperative and final visual acuity, time interval from intracranial hemorrhage (ICH) to vitrectomy, and any intraoperative and postoperative complications. RESULTS: The average age of the subjects and the Interval from ICH to vitrectomy were 43.0+/-11.0 years and 3.25+/-3.48 months respectively. Binocular involvement was found in two of the nine patients, and fundus findings were severe vitreous opacity in all cases, while sub-ILM hemorrhage at the posterior pole was seen in five eyes. Intraoperative retinal break was recorded at the 10 o'clock sclerotomy site in five eyes, and four of these five eyes were associated with sub-ILM hemorrhage. One patient underwent a scleral buckling operation four months postoperatively due to rhegmatogenous retinal detachment associated with a retinal tear at the 2 o'clock sclerotomy site. Visual acuity improved in all cases postoperatively, and the final visual acuity was over 0.6 in seven eyes. CONCLUSIONS: We can expect from early surgery a relatively good prognosis of visual acuity and prevention of complications. Due to the possibility of retinal breaks at the sclerotomy sites, we should keep in mind that cautious handling of intraocular instrument and complete removal of vitreous base may be necessary.

Postoperative Visual Recovery and Complications of Vitrectomy in Terson's Syndrome

PURPOSE: To investigate the visual recovery and complications of vitrectomy in Terson's syndrome. METHODS: A retrospective study was carried out on 11 eyes in 9 patients who had undergone pars plana vitrectomy for Terson's syndrome from October 2004 to June 2006. The factors assessed were age, gender, presence of hypertension, type of intracranial hemorrhage, preoperative and final visual acuity, time interval from intracranial hemorrhage (ICH) to vitrectomy, and any intraoperative and postoperative complications. RESULTS: The average age of the subjects and the Interval from ICH to vitrectomy were 43.0+/-11.0 years and 3.25+/-3.48 months respectively. Binocular involvement was found in two of the nine patients, and fundus findings were severe vitreous opacity in all cases, while sub-ILM hemorrhage at the posterior pole was seen in five eyes. Intraoperative retinal break was recorded at the 10 o'clock sclerotomy site in five eyes, and four of these five eyes were associated with sub-ILM hemorrhage. One patient underwent a scleral buckling operation four months postoperatively due to rhegmatogenous retinal detachment associated with a retinal tear at the 2 o'clock sclerotomy site. Visual acuity improved in all cases postoperatively, and the final visual acuity was over 0.6 in seven eyes. CONCLUSIONS: We can expect from early surgery a relatively good prognosis of visual acuity and prevention of complications. Due to the possibility of retinal breaks at the sclerotomy sites, we should keep in mind that cautious handling of intraocular instrument and complete removal of vitreous base may be necessary.

Terson's Syndrome : A case report

Terson's syndrome is one of the cerebro-ocular syndrome which entails the findings due to intraocular hemorrhage in association with increased intracranial pressure following subarachnoid hemorrhage. We reported a patient suffering from total blindness after basal ganglia hemorrhage, who was diagnosed as Terson's syndrome and vitrectomy was done. Our patient recovered normal visual acuity after vitrectomy, which fascilitated rehabilitative process. We also performed diffusion tensor tractography to investigate abnormalities of brain related to the visual dysfunction, which revealed decreased orientation and integrity of the right optic radiation. It is important to diagnose Terson's syndrome early because it is one of the cerebro-ocular syndrome which needs early intervention with consideration of the integrity of optic pathway.

Incidence, Treatment and Prognosis of Terson's Syndrome

PURPOSE: To investigate the incidence of Terson's syndrome, to find the proper time for its treatment, and to give a prognosis of visual acuity. METHODS: In order to investigate the incidence of Terson's syndrome, 228 patients were taken as the subjects of this study from among the total 275 patients who had been hospitalized in the neurosurgical department for a year. Forty-seven patients were excluded who developed vitreous hemorrhage due to any cause other than intracranial hemorrhage and could not be followed up for three months. In the fundus examination of study subjects, the incidence of Terson's syndrome based on preceding diseases and the patient age, and prognosis of visual acuity with surgical treatment were analyzed according to the Snellen chart, along with nine eyes of seven patients who showed vitreous hemorrhage. RESULTS The average incidence of Terson's syndrome between groups was 3.1%; it was 3.7% for patients with subarachnoid hemorrhage and 2.6% for the other patients (subdural hemorrhage, epidural hemorrhage). The 29% of the subjects were due to binocular involved. Patients in their 40's and 50's accounted for 6.0%, which was higher the percentage of any other age group. The decision as to whether or not to surgically treat Terson's syndrome was made based on the extent of visual acuity improvement during the three months after vitreous hemorrhage development. Thus, we observed comparatively good long-term prognoses for visual acuity and a low frequency of complications occurring. CONCLUSIONS: We expect a relatively good prognosis of visual acuity and a low occurrence of complications. More research similar to this case-control study is needed to confirm the usefulness of such therapy.

Incidence, Treatment and Prognosis of Terson's Syndrome

PURPOSE: To investigate the incidence of Terson's syndrome, to find the proper time for its treatment, and to give a prognosis of visual acuity. METHODS: In order to investigate the incidence of Terson's syndrome, 228 patients were taken as the subjects of this study from among the total 275 patients who had been hospitalized in the neurosurgical department for a year. Forty-seven patients were excluded who developed vitreous hemorrhage due to any cause other than intracranial hemorrhage and could not be followed up for three months. In the fundus examination of study subjects, the incidence of Terson's syndrome based on preceding diseases and the patient age, and prognosis of visual acuity with surgical treatment were analyzed according to the Snellen chart, along with nine eyes of seven patients who showed vitreous hemorrhage. RESULTS The average incidence of Terson's syndrome between groups was 3.1%; it was 3.7% for patients with subarachnoid hemorrhage and 2.6% for the other patients (subdural hemorrhage, epidural hemorrhage). The 29% of the subjects were due to binocular involved. Patients in their 40's and 50's accounted for 6.0%, which was higher the percentage of any other age group. The decision as to whether or not to surgically treat Terson's syndrome was made based on the extent of visual acuity improvement during the three months after vitreous hemorrhage development. Thus, we observed comparatively good long-term prognoses for visual acuity and a low frequency of complications occurring. CONCLUSIONS: We expect a relatively good prognosis of visual acuity and a low occurrence of complications. More research similar to this case-control study is needed to confirm the usefulness of such therapy.

Vitrectomy for Terson syndrome / 国际眼科杂志(Guoji Yanke Zazhi)

· AIM: To report the clinical results of vitrectomy for Terson syndrome.· METHODS: Twenty-one eyes of 15 patients with Terson syndrome underwent vitreous surgery with the mean follow-up of 19.1mo.· RESULTS: Incomplete posterior vitreous detachment(PVD) was found in 15 eyes (71.4 %), epiretinal membrane was formed in 7 eyes (33.3 %), and retinal detachment occurred in 4 eyes (19.0 %). Significant visual improvement occurred in all eyes after vitrectomy: visual acuity of 20/40 or better was achieved in 17 eyes (80.9 %)and 4 eyes (19.0 %) developed lens opacity.· CONCLUSION: Vitrectomy for Terson syndrome can provide good visual recovery, with low complication rate,including that of cataract.

An update of the clinical researches on Terson syndrome / 医学研究生学报

With the development of modern vitrectomy,some new ideas have been proposed concerning the treatment of Terson syndrome.Developed neurosurgery has offered more chances of survival to patients with subarachnoid hemorrhage(SAH).Terson syndrome,as the initial presentation,has gained more and more attention from ophthalmologists,though strict guidelines for its treatment have not yet been established.The paper reviews the progress in the clinical researches of Terson syndrome.

Terson's syndrome: Not a prognosticating factor of aneurysmal subarachnoid hemorrhage

Terson's syndrome has been implicated by previous studies as a strong predictor of poor outcome of patients with subarachnoid hemorrhage. There was even a recommendation to place patients with the syndrome in the next less favorable category. Hence this study was designed to provide a general profile of patients with Terson's syndrome and investigate whether the syndrome correlates with poor outcome. This study was done using a prospective cohort of patients seen at the Philippine General Hospital pay and charity wards from July 1, 1999 to June 30, 2000 diagnosed to have aneurysmal subarachnoid hemorrhage. Detailed ophthalmological examination was done and data were collected using a standard database. Patients were then followed up at 2 weeks, 1 month and 3 months to determine outcome (using Glasgow Outcome Score). Data collected were subjected to univariate analysis using chi square and/or Fisher test to determine significant correlation of variables with Terson's syndrome and to determine significance of Terson's syndrome as a predictor of poor outcome. A total of 52 patients were included in the study. The general demographic profile of patients with Terson's syndrome was comparable to that of the study population. The frequency of Terson's syndrome was 13.4 percent. There were no statistically significant differences in outcomes among patients with and without Terson's syndrome. However, positive correlation between laterality of Terson's syndrome with the side of aneurysm was shown. Although results were not significant, funduscopic examination remains to be warranted as an important part of diagnostic work-up of aneurysmal subarachnoid hemorrhage patients. When present, the laterality of Terson's syndrome may give a clue to the presence and side of the aneurysm.

Incidence and Postoperative Visual Outcome of Terson's Syndrome

PURPOSE: The purpose of the study A was to determine the incidence of Terson's syndrome. The purpose of the study B was to assess the outcome of vitrectomy for Terson's syndrome. METHODS: In the study A, We have examined fundus by direct ophthalmoscope in 96 eyes of 62 persons with subarachnoid hemorrhage, subdural hemorrhage and epidural hemorrhage from March 2000 to June 2001. If we needed more examination, further evaluation was performed. In the study B. We have examined 8 eyes with Terson's syndrome retrospectively from 1997 to 2000. Visual outcome of operation was examined. RESULTS: A. The incidence of Terson's syndrome was 4.3% (4 eyes by 96eyes). Other ophthalmic findings were retinal hemorrhage (1 eye), central retinal artery occlusion (1 eye) and optic atrophy (1 eye). B. The final visual acuity was over 0.5 in 5 of 8 eyes and Visual acuity improved at a full cases postoperatively. CONCLUSIONS: The incidence of Terson's syndrome was 4.3%. The final visual acuity of Terson's syndrome was relatively good. Therefore, We must closely examine the fundus of patient with subarachoid hemorrhage, subdural hemorrhage and epidural hemorrhage patients. and We can also perform vitrectomy for vitreous hemorrhage, if Terson's syndrome is suspected.

Terson's Syndrome in Aneurysmal Subarachnoid Hemorrhage

Terson's syndrome is the oculocerebral syndrome of retinal and vitreous hemorrhage associated with spontaneous subarachnoid hemorrhage(SAH) or all forms of intracranial bleeding. Recent observations indicate that the patients with spontaneous subarachnoid hemorrhage have an 18% to 20% concurrent incidence of retinal and vitreous hemorrhages and about 4% incidence of viterous hemorrhage alone. Therefore, clinical ophthalmologic findings may have a significant diagnostic and prognostic value for the clinician. Total of 627 consecutive patients with aneurysmal subarachnoid hemorrhage were retrospectively studied by means of indirect fundoscopy to address the question of occur and prognostic implications of vitreous hemorrhage after subarachnoid hemorrhage from January 1993 to December 1996. Among these, we experienced 21 patients with vitreous hemorrhage(Terson's syndrome). The patients with vitreous hemorrhage commonly occurred in anterior communicating and internal carotid artery aneurysm. Twelve patients had intraocular hemorrhage within 48 hours after SAH. There were bilateral involvement in 15 cases, and the 14 experienced complete recovery of vision following massive intravitreal hemorrhage. A favorable surgical outcome was obtained in 14 of 21 patients(66.7%) and a satisfactory result in vision was achieved in 15 cases among 17 survivors(88.2%). From these results, we emphasize the significance of ocular findings in patients with aneurysmal subarachnoid hemorrhage.

Terson's Syndrome due to Subarachnoid Hemorrhage after Rupture of MCA Bifurcation Aneurysm

In the literature, Terson's syndrome most commonly co-occurs with subarachnoid hemorrhage(SAH) secondary to rupture of an A-com or ICA aneurysm. It is usually observed bilaterally and the prognosis is poor. The authors report two rare cases of unilateral Terson's syndrome after rupture of MCA bifurcation aneurysm rupture. In both cases, retinal hemorrhage was noticed after early aneurysmal clipping ; after these were conservatively treated, the visual acuity of one patient improved slightly and that of the other showed no change. For early detection and proper management of retinal hemorrhage after subarachnoid hemorrhage, early and periodic fundoscopic examination appears to be important.