Download Sub Internal Limiting Membrane Bleed and Perimacular

216
Kerala Journal of Ophthalmology
Vol. XIX, No. 2
PHOTO
ESSAY
Sub Internal Limiting Membrane Bleed and
Perimacular Folds in Terson Syndrome
Dr. Sonia Rani John DNB, Dr. Valsa Stephen MS DO DNB, Dr. Meena Chakrabarti MS DO DNB,
Dr. Arup Chakrabarti MS DNB
In the year 1900, Terson described the presence of a
dome shaped subhyaloid haemorrhage associated with
intracranial haemorrhage. Vander Linder and Chisholm
(1974) described the occurrence of a sub ILM
component in the premacular haemorrhage. Review of
subsequent literature gives descriptions of perimacular
folds (Keithen & Meiler: 1992) and also correlates a
higher incidence of epiretinal membranes with dense
vitreous haemorrhage and bleeding under the Internal
Limiting Membrane.
This photo essay contains essentially intraoperative still
photographs taken during vitrectomy procedure for a
21 year old engineering student with traumatic Terson
Syndrome following a road traffic accident. The
preoperative ocular evaluation revealed a visual acuity
of hand movements on the right side with accurate
projection and dense vitreous haemorrhage with
subtotal posterior vitreous detachment on B-scan
ultrasonography.
The photographs depict the stages of induction of
posterior vitreous detachment, presence of sub ILM
bleed and demonstrates the technique of peeling the
elevated ILM and draining the sub ILM blood.
(Fig. 1 to Fig. 5)
intracranial haemorrhage. Other associated findings
and long term sequelae include epiretinal membrane
(ERM) formation, pigmentary macular changes, cystic
intraretinal changes (CIRC); epimacular membrane
formation, macular hole and retinal detachment;
ERM formation is the commonest sequelae following
Terson Syndrome and occurs in 40% of cases. A higher
incidence of ERM formation has been described in
eyes undergoing conservative management for the
intraocular bleed associated with Terson Syndrome.
The exact pathogenesis of this sequelae is not known
and it is postulated to be caused by the direct trauma
to the ILM during the seepage of blood beneath it, with
resultant glial proliferation.
Perimacular retinal folds are circular folds spanned by
glistening membrane which on electron microscopy
proved to be Internal Limiting membrane of the retina.
These folds are hence associated with denser vitreous
haemorrhage with sub ILM bleeding.
Studies on the treatment options in Terson Syndrome
favour an early surgical intervention in the form of pars
plana vitrectomy with drainage of sub ILM bleed,to
reduce the incidence of sequelae like ERM formation.
Discussion
References
Terson Syndrome is characterized by pre, intra or
subretinal haemorrhage associated with any form of
1.
Garcia Arumi J, Corcostegui B, Salvador F, Epiretinal
Membrane In Terson Syndrome : A Clinicopathological
Study Retina, Vol (24)
2.
MacRae M, Teasell R.W, Canny C, Bilateral Retinal
Detachment associated with Terson syndrome. Retina
1994. 14(5) 467-9
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011
Address for Correspondence: Dr. Sonia Rani John, Chakrabarti Eye Care Centre,
E-mail: [email protected]
June 2007
Sonia R. John et al. - Terson Syndrome
217
(a)
Fig. 1. Dense organized vitreous haemorrhage
(b)
Fig. 2. PVD induction using Flute needle
(c)
Fig. 3. Demonstrates the presence of Sub ILM Bleed
(a)
Fig. 5 a, b, c Drainage of Sub ILM blood
using Flute needle
(b)
Fig. 4 a & b Stages of ILM Peeling
3.
Kuhn F, Moris: Terson Syndrome. Results of Vitrectomy
and Significance of Vitreous Haemorrhage in Patients
with Subarachnoid Haemorrhage Witherspoon
Ophthalmol 1998; 105; 472-477
4.
Sobol W.M, T.A. Weingest Long Term Visual outcome in
Terson syndrome Schultz; Ophthalmol 1992 May 99(5)
647