1. Grand Rounds Brooke LW Nesmith, M.D., J.D.
University of Louisville School of Medicine
Department of Ophthalmology & Visual Sciences
5/2/2014 1

2. Presentation CC: Sudden onset floaters OS x 1 day
HPI: 59 year old white male with diffuse subarachnoid hemorrhage who had undergone right frontal ventriculostomy subsequently began complaining of sudden onset of multiple large floaters OS.
He had presented the day before with the ‘worst headache of his life,’ nausea, vomiting, and stiff neck.

3. Presentation POHx: None
PMHx: Seasonal allergies, hypertension, coronary artery disease, chronic obstructive pulmonary disease
Meds: Lisinopril, clonidine, metoprolol, inhalers
Allergies: NKDA

4. Exam VA (near, with correction) OD 20/50 OS 20/30 T (tonopen)
Pupils
OD 3mm OS 3mm
no RAPD

5. Exam OD OS Ext/L/L wnl wnl ANTERIOR SEGMENT (pen light exam)
Conj wnl wnl
K wnl wnl
AC formed formed
Iris wnl wnl
Lens +nuclear sclerosis + nuclear sclerosis
DFE vitreous, pre- and intra-retinal hemorrhages
OS > OD 5

6. CT Scan 6

7. Fundus Exam OU 7

8. Assessment/Plan
59 year old white male with diffuse subarachnoid hemorrhage and bilateral retinal hemorrhages consistent with Terson’s syndrome
Observation / follow up outpatient

9. Hospital Course
Cerebral angiogram: negative for arterial malformation or aneurysm
Developed pneumonia and subsequent respiratory failure, was intubated
Developed atrial fibrillation
Underwent total abdominal colectomy secondary to ischemic bowel
Multiorgan system failure - deceased

10. Terson’s Syndrome
Named after the French ophthalmologist Albert Terson in 1900
Defined as occurrence of an intraocular hemorrhage associated with an intracranial hemorrhage
Occurrence reported in literature is 12.5% to 40% of individuals with intracranial hemorrhage
1st described by Moritz Litten, German ophthalmologist in 1881
Intraocular hemorrhage can be subretinal, intraretinal, preretinal, subhyaloid, or intravitreal and at present, any type of intracranial hemorrhage accompanied by vitreous or retinal hemorrhage is known as TS
Originally diagnosis just included VH

11. Terson’s Syndrome Pathophysiology
Two proposed mechanisms:
Intracerebral blood directly connects with the optic nerve subarachnoid space
Large increase in intracranial pressure leads to increased orbital venous pressure
Optic nerve hemorrhage were locally multifocal and not extensions of intracranial blood
Ko F, Knox D. The ocular pathology of Terson’s Syndrome. Ophthalmology 2010;117:

12. Terson’s Syndrome Prognostic Value
Prospective, consecutive case series of 47 emergency room patients with diagnosis of acute subarachnoid hemorrhage
Fourteen patients (29%) were diagnosed with Terson’s Syndrome
Bilateral 57%
Vitreous hemorrhage 14.2%
50% died
Sung W, Arnaldo B, Sergio C, et al. Terson’s syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage. Acta Ophthalmologica 2011;89:
9% died in those who didn’t have Terson’s Syndrome

13. Terson’s Syndrome Treatment
Spontaneous resorption
Vitrectomy
Prospective, uncontrolled study of 102 patients with subarachnoid hemorrhage
20/102 (19.6%) patients had Terson’s syndrome
9 eyes (40%) underwent vitrectomy (mean interval to surgery was 4.4 months)
4 eyes underwent internal limiting membrane peeling
Visual acuity significantly improved in all patients
wait 3-6 months – current recommendations; difference if bilateral vs unilateral
Skevas C, Czorlich P, Knospe V, et al. Terson’s Syndrome-Rate and surgical approach in patients with subarachnoid hemorrhage. Ophthalmology 2014:1-6

14. Terson’s Syndrome
As the presenting symptom of intracranial hemorrhage: 2 case reports
50yo male presented with decrease vision in right eye
admitted for investigation
lost consciousness
large intraventricular bleed
38yo male presented with sudden loss of vision in both eyes
no other neurological
symptoms at presentation
subarachnoid hemorrhage
Subbiah S, Wilson S, Best R. An unusual presentation of Terson’s syndrome. Eye 2007;21:
Murthy S, Salas D, Hirekataur S, Ram R. Terson’s syndrome presenting as an ophthalmic emergency. Acta Ophthalmol Scan 2002:80:

15. References
Ko F, Knox D. The ocular pathology of Terson’s Syndrome. Ophthalmology 2010;117: Manschot, A. Subarachnoid hemorrhage; intraocular symptoms and their pathogenesis. Am J ophthalmol 1954;38:501-5 Michalewska Z, Michalewski J, Nawrocki J. Possible methods of blood entrance in Terson syndrome. Ophthalmic Surg Lasers Imaging 2010;41:S42-S49 Murthy S, Salas D, Hirekataur S, Ram R. Terson’s syndrome presenting as an ophthalmic emergency. Acta Ophthalmol Scan 2002:80: Sung W, Arnaldo B, Sergio C, et al. Terson’s syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage. Acta Ophthalmologica 2011;89: Skevas C, Czorlich P, Knospe V, et al. Terson’s Syndrome-Rate and surgical approach in patients with subarachnoid hemorrhage. Ophthalmology 2014:1-6 Subbiah S, Wilson S, Best R. An unusual presentation of Terson’s syndrome. Eye 2007;21:

16. Thank you.