Case of the Month I November 2020

Case of the Month
November 15, 2020

The Case

The patient was a 62-year-old woman with a complaint of a single, stationary, vertical line in the left eye, who was found to have hemorrhages in each eye. Her history was remarkable for a fall two months previously, and a CT scan at that time showed an intracranial hemorrhage. She had not suffered significant neurologic damage, and a more recent CT scan showed clearing of the blood. She also had a history of controlled hypertension.

What is the most likely diagnosis? Is any treatment needed?

This patient likely had Terson’s syndrome, in which an intracranial hemorrhage results in a sudden increase in intracranial pressure, which leads to disc swelling and intraretinal and preretinal hemorrhages. Though there are different theories regarding pathophysiology, a leading theory is that a rapid change in intracranial pressure ruptures epipapillary and peripapillary capillaries. The retinal hemorrhages can be deep (blot) or superficial (flame-shaped). The preretinal hemorrhages can be sub-internal limiting membrane, subhyaloid (if there has not been a complete posterior vitreous separation, as in our patient, who has boat-bottom-shaped blood accumulation), or intravitreal.

Though not obvious from these images, a thin layer of subhyaloid hemorrhage in the left eye could account for the stationary vertical line described by the patient. The blood had largely cleared when the patient returned two months later, and the patient had no visual complaints. Most patients recover vision, though occasionally vitrectomy is needed for non-clear vitreous hemorrhage. Also, an epiretinal membrane in the macula can develop if there is a sub-internal limiting membrane hemorrhage.

Interestingly, there is poor correlation between the severity of the intracranial hemorrhage and the development of Terson’s syndrome. Also, adults seem more susceptible to Terson’s syndrome than children, perhaps because adults have less resilient blood vessels.

Case Photos

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This patient likely had Terson’s syndrome, in which an intracranial hemorrhage results in a sudden increase in intracranial pressure, which leads to disc swelling and intraretinal and preretinal hemorrhages. Though there are different theories regarding pathophysiology, a leading theory is that a rapid change in intracranial pressure ruptures epipapillary and peripapillary capillaries. The retinal hemorrhages can be deep (blot) or superficial (flame-shaped). The preretinal hemorrhages can be sub-internal limiting membrane, subhyaloid (if there has not been a complete posterior vitreous separation, as in our patient, who has boat-bottom-shaped blood accumulation), or intravitreal.

Though not obvious from these images, a thin layer of subhyaloid hemorrhage in the left eye could account for the stationary vertical line described by the patient. The blood had largely cleared when the patient returned two months later, and the patient had no visual complaints. Most patients recover vision, though occasionally vitrectomy is needed for non-clear vitreous hemorrhage. Also, an epiretinal membrane in the macula can develop if there is a sub-internal limiting membrane hemorrhage.

Interestingly, there is poor correlation between the severity of the intracranial hemorrhage and the development of Terson’s syndrome. Also, adults seem more susceptible to Terson’s syndrome than children, perhaps because adults have less resilient blood vessels.

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