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Answers: 2007 series -  October 23, 2007 Lecture 10 of 52  NEXT»

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A 46 year-old white female presented with several serious health issues.  She had a coil for a subarachnoid hemorrhage done two days ago, she has uncontrolled diabetes, and she has some serious alcohol issues.  She says she cannot see out of her left eye and the neurosurgeon who placed the coil thinks that she is bleeding intracranially from diabetes. 

You examine the patient's eyes and these are the pertinent findings:

Visual acuity:  OD, 20/50; OS, light perception

Annterior segment is essentially normal; no rubeosis; trivial lens opacities.

See retinal pictures OD; no view OS

Concerned about not having a view into the left eye, you do an ultrasound.  As suspected, the patient has a relatively dense vitreous hemorrhage but no signs of retinal detachment.

1.  Keeping the patient's history in mind, you now feel rather confident in making a diagnosis.  And so, what do you write as Impression #1 on your consult?  
 

d -- Terson's syndrome

Terson's syndrome is a relatively uncommon condition characterized by intraocular hemorrhages secondary to subarachnoid or subdural hemorrhages.  Although uncontrolled diabetes (which this lady had) could certainly cause vitreous hemorrhage, the fundus findings in the right eye were not at all consistent with diabetic retinopathy.  

 

2.  Having arrived at your impression, it is now time to formulate a plan.  What do you write?  
 

c -- "prudent observation-- reevaluate as outpatient in two weeks"

 

3.  The patient returns to your clinic a month later, still with poor vision (count fingers now) OS.  A fluorescein angiogram (FA) is performed in clinic.  What about the angiogram really cinches your diagnosis?
 

 c -- both retinal and subretinal hemorrhages

Key to this diagnosis were the history of subarachnoid hemorrhage, viteous hemorrhage (OD), and multi-leveled hemorrhages -- vitreous cavity, subretinal space, and the sensory retina.  The FA demonstrates this beautifully-- consider the large splotch of peripapillary blood-- it is definitely in the superficial sensory retina, as it obscures the underlying vessels.  However, the other hemes (perimacular) reside under the retinal vessels.  This,along with the vitreous hemorrhage, is classic for Terson's.

 

4. The patient is complaining about waiting for her blood to clear OS, and you decide to proceed with a vitrectomy.  Before doing this, you explain that as a reasonably young  patient (46 years old) with a relatively formed vitreous, it might take a while for all the blood to clear.  She seems to understand this.  And although it was certainly within the standard of care to wait on the vitrectomy in this woman, in what patient with this condition is it imperative to operate immediately?

a -- an infant -- unilateral vitreous hemorrhages can lead to amblyopia

As far as the timing of vitrectomy is concerned, classically it is only mandated to urgently vitrectomize infants, as they are particularly predisposed to early-onset amblyopia. 

Reference:

Basic and Clinical Science Course, American Academy of Ophthalmology, 2006-2007, Section 12, Retina and Vitreous, p. 95.

 


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