Optical coherence tomographic findings in Terson syndrome

Eric L. Crowell, MD, MPH*^†Amde Selassie Shifera, MD, PhD*

Running title: OCT in Terson syndrome

From the *Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland

^†Current address: University of Texas Health Sciences Center at Houston, Houston, Texas

Reprint requests: Amde Selassie Shifera, MD, PhD, 600 N. Wolfe St, Woods Building, Room 471, Baltimore, MD 21287. TEL: 410-955-1966. E-mail: ashifer3@jhmi.edu

Conflict of interest: The authors have no conflict of interest to disclose.

Source of funding: AS is supported an institutional grant to the Wilmer Eye Institute from Research to Prevent Blindnessand by donations from grateful patients.

Keywords: intraretinal hemorrhage; optical coherence tomography; subretinal hemorrhage; sub-internal limiting membrane hemorrhage; Terson syndrome

Summary statement: Optical coherence tomography was used to demonstrate the multi-layered retinal hemorrhage that developed in the macula of a patient with Terson syndrome and to evaluate the change in the appearance of the hemorrhage over time.

A 62-year-old man presented with a 5-day history of central scotoma of his left eye. Five days prior to presentation he hit his head against the bottom of a trailer. Approximately 30 minutes after the accident he noticed a dark grayish spot in the center of his vision. He also reported that when looks at a light source the light would look reddish. The patient also reported having a generalized headache of a moderate degree that lasted for 15 minutes after the accident.

At presentation, his visual acuity in the left eye was counting fingers at 3 feet. On examination he was found to have a layered hemorrhage in the macula of the left eye (Figure 1A). Spectral domain optical coherence tomography (OCT; Spectralis system; Heidelberg Engineering) showed multi-layered hemorrhagein the macula of the left eye.Specifically, the OCT showed sub-internal limiting membrane (ILM) hemorrhage (both clotted and non-clotted), intraretinal hemorrhage and subretinal hemorrhage (Figure 1B to G). Examination of the right eye was non-remarkable. A computed tomography of the head done at presentation did not show any evidence of intracranial hemorrhage. No intervention was done at the initial presentation.

When the patient returned for follow-up one month later, his vision remained counting fingers (at 2 feet). OCT scan of the left eye showed resolution of the sub-ILM hemorrhage; the subretinal hemorrhage was largely resolved but the patient wasstill having intraretinal hemorrhage which appeared increased in amount (Figure 2A and B). The patient elected observation; however, he did not return for further follow-up. Even though computed tomography of the head was negative, the history and ocular findings are consistent with Terson syndrome. The mechanism of Terson syndrome is unknown but is believed to be due to a spike in intracranial pressure and the resultant rupture of retinal vessels.^1-4

REFERENCES

1.         Augsten R, Konigsdorffer E and Strobel J. Surgical approach in terson syndrome: vitreous and retinal findings. Eur J Ophthalmol 2000; 10:293-296.

2.         Biousse V et al. The ophthalmology of intracranial vascular abnormalities. Am J Ophthalmol 1998; 125:527-544.

3.         Gress DR, Wintermark M and Gean AD. A case of Terson syndrome and its mechanism of bleeding. J Neuroradiol 2013; 40:312-314.

4.         Kapoor S. Terson syndrome: an often overlooked complication of subarachnoid hemorrhage. World Neurosurg 2014; 81:e4.

FIGURE LEGENDS

Fig. 1. Images of the left eye at presentation. A. Pseudocolor fundus photograph of the left eye (Optos ultra-widefield imaging device; Optos, Marlborough, MA). B to F. Horizontal optical coherence tomographic scans through the macula of the left eye. G. A vertical optic coherence tomographic scan through the macula of the left eye. IRH, intraretinal hemorrhage; SILMH*, clotted sub-internal limiting membrane hemorrhage; SILMH**, non-clotted sub-internal limiting membrane hemorrhage; SRH; subretinal hemorrhage.

Fig 2. Optical coherence tomography of the left eye one month after presentation. A. A horizontal scan through the macula. B. A vertical scan through the macula.