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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