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Download Terson`s Syndrome - University of Louisville Ophthalmology
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Grand Rounds Brooke LW Nesmith, M.D., J.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 5/2/2014 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. Presentation POHx: None PMHx: Seasonal allergies, hypertension, coronary artery disease, chronic obstructive pulmonary disease Meds: Lisinopril, clonidine, metoprolol, inhalers Allergies: NKDA Exam VA (near, with correction) OD 20/50 OS 20/30 T (tonopen) OD 20 Pupils OS 20 OD 3mm OS 3mm no RAPD Exam ANTERIOR SEGMENT (pen light exam) Ext/L/L Conj K AC Iris Lens DFE OD OS wnl wnl wnl formed wnl +nuclear sclerosis wnl wnl wnl formed wnl + nuclear sclerosis vitreous, pre- and intra-retinal hemorrhages OS > OD CT Scan Fundus Exam OU Assessment/Plan 59 year old white male with diffuse subarachnoid hemorrhage and bilateral retinal hemorrhages consistent with Terson’s syndrome – Observation / follow up outpatient 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 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 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 Ko F, Knox D. The ocular pathology of Terson’s Syndrome. Ophthalmology 2010;117:1423-1429 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;89:544-547 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 Skevas C, Czorlich P, Knospe V, et al. Terson’s Syndrome-Rate and surgical approach in patients with subarachnoid hemorrhage. Ophthalmology 2014:1-6 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;21:855-856 Murthy S, Salas D, Hirekataur S, Ram R. Terson’s syndrome presenting as an ophthalmic emergency. Acta Ophthalmol Scan 2002:80:665-666 References Ko F, Knox D. The ocular pathology of Terson’s Syndrome. Ophthalmology 2010;117:1423-1429 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 2002:80:665-666 Sung W, Arnaldo B, Sergio C, et al. Terson’s syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage. Acta Ophthalmologica 2011;89:544-547 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;21:855-856 Thank you.
