Features
Terson syndrome is generally defined as the occurrence of any intraocular hemorrhage in patients suffering from cerebral diseases with raised intracranial pressure, classically subarachnoid hemorrhage (SAH). It usually develops within a couple of hours after the onset of SAH, but it can rarely develop as late as 6 weeks. Less frequently, it may be caused by intracerebral hemorrhage, epidural/subdural hematoma, severe brain injury, spinal SAH, intraventricular hemorrhage, or endoscopic third ventriculostomy. Terson syndrome can occur at any age, but most commonly affects adults between the age of 30 and 60. SAH patients with a low Glasgow Coma Scale (GCS) and high Hunt & Hess scale (H&H) have a higher reported incidence of Terson syndrome. The presence of Terson syndrome following SAH is associated with a higher mortality rate of up to 50–60%.
81.1.1 Common Symptoms
Common symptoms are decreased vision, floaters, visual field defects or blindness, with a history of SAH. Intraocular hemorrhage that involves the macular or visual axis significantly impacts visual acuity. Accompanying conditions such as epiretinal membrane formation, secondary macular holes, retinal detachment, retinal hemosiderosis, or optic neuropathy may exacerbate visual impairment and final visual outcomes.
Visual symptoms are often reported after brain surgery or when patients regain consciousness.
81.1.2 Exam Findings
Terson syndrome develops in 20 to 40% of acute aneurysmal SAH, and vitreous hemorrhage (VH) occurs in 3 to 5% of cases, but actual incidence may be higher due to the high early mortality rate hindering accurate diagnosis. Approximately 60% of cases are bilateral. Intraocular hemorrhage may involve various locations and multiple layers of the retina. These include the vitreous, subhyaloid, sub-internal limiting membrane (ILM), intraretinal, and subretinal spaces.
81.2 Key Diagnostic Tests and Findings
81.2.1 Optical Coherence Tomography
Optical coherence tomography (OCT) helps identify the precise location of premacular, submacular, and intraretinal hemorrhage when performance is feasible (▶ Fig. 81.1, ▶ Fig. 81.2).
Fig. 81.1 (a) Fundus photo and (b) optical coherence tomography (OCT) performed 2 weeks after the onset of subarachnoid hemorrhage. The horizontal B-scan reveals a small amount of subretinal hemorrhage at the fovea (arrow).
Fig. 81.2 (a) Fundus photos and (b) optical coherence tomography performed 2 months after the onset of subarachnoid hemorrhage. The vertical B-scan illustrates the existence of sub-internal limiting membrane hemorrhage (arrow) and incomplete separation of the posterior hyaloid (arrowhead). The OCT beam is partially blocked by vitreous hemorrhage.
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