gms | German Medical Science

Objective: Terson syndrome (TS) is commonly defined as the occurrence of an intraocular hemorrhage (IOH) associated with a subarachnoid hemorrhage (SAH). IOH may be subretinal, intraretinal, preretinal, subhyaloid, or intravitreal, and, at present, any type of intracranial hemorrhage accompanied by vitreous (VH) or retinal hemorrhage is known as TS. The mechanism causing intraocular bleeding remains unclear. A careful ophthalmological examination (OE) should be performed in all unconscious or confused patients being admitted to the hospital. Currently, there are no clear guidelines for the timing of ophthalmological intervention. Spontaneous clearance of VH may be expected within 10 to 12 months, but vitreous surgery can expedite this process, especially in cases of nonclearing VH. The gold standard for the correct diagnosis of TS is indirect funduscopy which requires iatrogenic mydriasis. The aim of this prospective interdisciplinary study, was to evaluate the incidence of TS, the effect of surgery (pars plana vitrectomy-PPV) in patients with persistent non resorbing vitreous haemorrhage (VH) and to scrutinize if ocular ultrasound (OUS) may be established as a standard diagnostic tool in non-specialized intensive care and neurological rehabilitation units to screen for ocular bleedings and thus preventing worse clinical outcome with visual impairment. The primary endpoint of the ocular ultrasound examination was description of sensitivity, specificity, positive and negative predictive value and accuracy of ocular ultrasound in the detection of TS. The secondary endpoint was description of a learning curve.

Methods: All SAH patients who were admitted to our clinic over a 24 period were screened for TS following written consent by the patient or by the legal representative. 102 patients in total were included in this study. Ophthalmological examination and OUS examination (OUS examination war performed by two investigators, an ophthalmologist and a neurosurgeon) was performed on day one and day 14. A follow up examination after 3 months was planned for all TS patients. A standard ultrasound system (General Electrics, Vivid S6; GE 8L-RS, General Electrics Healthcare, Chalfont St Giles, United Kingdom high-resolution linear probe-10 MHz) was performed on day one and day 14 after written consent. For patients with non resorbing VH after the follow up examination of 3 months, PPV was indicated and planned.

Results: The incidence of TS was 19.6 % (20/102) with a predominance among female patients (24,2% female vs 11,1% male patients). A PPV was performed in 9 eyes out of 8 patients due to non resorbing VH. In 4 eyes of 4 patients, PPV had to be combined with ILM peeling due to sub-ILM bleeding. Visual acuity pre-OP was hand motion and 0,9 post surgery.

Both investigators who performed OUS fared well. Investigator I presented a sensitivity 52.4%, positive predictive value 57.9% and a specificity of 90.4% and a negative predictive value of 88.2%. Investigator II was found to have a specificity of 100% with a negative predictive value of 84.7% and a sensitivity of 21.1% with a positive predictive value of 100%. The learning curve of both investigators improved.

Conclusion: Our study presents solid data that PPV is an effective and safe method for the removal of persisting non resorbing VH and for the visual rehabilitation of patients. Today, indirect funduscopy is the gold standard for diagnosing TS, but iatrogenic mydriasis may mask life threatening complications, especially in neurocritically ill patients. Our results have shown that OUS as a bedside, non-invasive tool is of high diagnostic value and provides high accuracy detecting ocular pathologies. This is of special interest to neuro-intensive care and neurological rehabilitation units, as OUS is not routinely performed in SAH patients, where IOH followed by temporary or permanent visual acuity may affect many patients. Our study has confirmed that OUS is a safe and useful technique in diagnosing pathological changes of the ocular globe. Its ease of handling is accompanied by a fast accelerating learning curve, further improving diagnostic reliability. This should encourage neurointensive care physicians to become familiar with OUS to diagnose IOH, thereby differentiating between a pathology requiring immediate ophthalmologic consultation (such as retinal detachment and intraocular foreign bodies) from those findings (such as vitreous hemorrhage or retinal hemorrhage) which can be followed up on an outpatient basis.In this context, ocular ultrasound is a very important tool to augment the diagnostic capabilities of neurointensive care and neurological rehabilitation units. Nevertheless, indirect funduscopy remains the gold standard in the diagnosis of intraocular hemorrhage (IOH), and should be performed in all patients suffering from subarachnoid hemorrhage (SAH), traumatic brain injury (TBI) and intracerebral hemorrhage (ICH) as soon as the patient leaves life supporting treatment.