Letters
Neurology Ophthalmology
Volume 197 - Issue 3

Terson syndrome: the need for fundoscopy in subarachnoid haemorrhage

Authors:  Akbar N Ashrafi, Rahul Chakrabarti and John Laidlaw

Med J Aust 2012; 197 (3): 152. || doi: 10.5694/mja12.10642
Published online: 6 August 2012
To the Editor: Patients who survive subarachnoid haemorrhage (SAH) are at significant risk of visual impairment, further complicating their recovery. This may arise as a result of Terson syndrome,1 which is the phenomenon of intraocular haemorrhage associated with any intracranial bleed and raised intracranial pressure. We report a case of missed Terson syndrome at a tertiary referral centre. A 36-year-old previously well woman presented with a ...
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To the Editor: Patients who survive subarachnoid haemorrhage (SAH) are at significant risk of visual impairment, further complicating their recovery. This may arise as a result of Terson syndrome,1 which is the phenomenon of intraocular haemorrhage associated with any intracranial bleed and raised intracranial pressure. We report a case of missed Terson syndrome at a tertiary referral centre.

A 36-year-old previously well woman presented with a Glasgow Coma Scale (GCS) score of 7 after a World Federation of Neurological Surgeons (WFNS) Clinical Grade 4 SAH, with equal and reactive pupils and no afferent pupillary defect. She was treated with craniotomy and clipping of a ruptured aneurysm of the right M2 (Sylvian segment of the middle cerebral artery). Despite her poor neurological condition, the patient made slow but gradual progress. It was not until Day 65, when her GCS score was 14, that she described difficulty with her vision. Ophthalmic examination of both eyes revealed visual acuity of counting fingers only and a poor red reflex, and fundoscopy showed an obscured view of the retina due to vitreous haemorrhage (Box). The patient underwent bilateral vitrectomy, and was subsequently transferred for rehabilitation. Review at 6 months showed acuities of 6/36 and 6/24 in the right and left eye, respectively.

The incidence of Terson syndrome in patients who survive SAH is approximately 2%–14%.2,5 It is usually bilateral, and can progress to retinal traction, retinal detachment, and proliferative retinopathy if not treated.3,4 Terson syndrome is associated with increased morbidity compared with SAH without an intraocular bleed.5

Diagnosis of Terson syndrome may be delayed for numerous reasons. In patients with SAH, the need for neurological monitoring often restricts the dilatation of pupils for ophthalmic assessment. Further, patients with higher WFNS grade SAH have greater cognitive impairment, limiting their ability to communicate visual disturbance or comply with testing. Unfortunately, these patients are also at most risk of Terson syndrome. We recommend routine bedside ophthalmoscope examination in all patients with SAH, as soon as the patient’s neurological status is stable.

Visual impairment in patients recovering from SAH has important prognostic and functional implications. The timely diagnosis of Terson syndrome may prevent further morbidity and facilitate recovery and rehabilitation. This case emphasises the need for early ophthalmic screening in all patients with SAH.

Previtrectomy photograph and fundoscopy image

A: Previtrectomy photograph showing poor retinal red reflex and subconjunctival injection in one of the affected eyes. B: Fundoscopy image of the same eye showing an obscured retinal view due to vitreous haemorrhage.

Authors

  • Akbar N Ashrafi1
  • Rahul Chakrabarti2
  • John Laidlaw3
  • 1. Mater Adult Hospital, Brisbane, QLD.
  • 2. Centre for Eye Research Australia, University of Melbourne, Melbourne, VIC.
  • 3. Royal Melbourne Hospital, Melbourne, VIC.

Correspondence: Akbar.Ashrafi1@gmail.com

Competing interests

No relevant disclosures.

References

View this article on Wiley Online Library