Pars plana vitrectomy with intraoperative optical coherence tomography for sub-internal limiting membrane fibrosis excision in a child with Terson syndrome: Surgical and pathological correlation

Abstract

Purpose: To report the intraoperative optical coherence tomography (OCT)-guided surgery of a consolidated sub-internal limiting membrane (ILM) hemorrhage that developed into a sub-ILM fibrotic membrane in a child with a history of Terson syndrome.

Observations: A one year-old boy with a history of Terson syndrome due to a motor vehicle accident presented three months after trauma with a white feather-shaped membrane in the left macula. Preoperative OCT showed a preretinal hyperreflective tissue at the foveal center. The patient underwent pars plana vitrectomy. After separation of the posterior hyaloid, intraoperative OCT did not show any change in structural components. After peeling the ILM, the fibrotic membrane persisted. A bent 30-gauged needle was used to create a plane of dissection in the adherent sub-ILM membrane, which was then peeled with ILM forceps without complication. Post-operative OCT confirmed complete excision without evidence of macular edema. Pathology results indicated presence of fibrocellular tissue that contained hemosiderin, consistent with old organized hemorrhage as a component of the membrane.

Conclusion and importance: Sub-ILM hemorrhage may persist as a tautly adherent fibrotic membrane that can mimic the appearance of an epiretinal membrane or a chronic subhyaloidal hemorrhage during examination, especially in young children. Intraoperative OCT may aid in select complex macular surgery cases to better delineate the planes of dissection during sub-ILM fibrosis excision.

Keywords: Optical coherence tomography; Retinal hemorrhage; Sub-internal limiting membrane fibrosis; Sub-internal limiting membrane hemorrhage; Terson syndrome; Vitrectomy.

Fig. 1

Preoperative fundus photo (Box A) and OCT shows preretinal membrane. Postoperative fundus photo (Box B) shows absence of the sub-ILM membrane one month after the surgery.

Fig. 2

B-scan ultrasound shows a hyperreflective membrane (arrow) in the posterior pole of the left eye.

Fig. 3

Intraoperative fundus photo of the left eye shows a white feather-shaped membrane near the fovea (image appears inverted due to being from the surgeon's point of view). Intraoperative optical coherence tomography (OCT) shows a hyperreflective density below the internal limiting membrane (ILM).

Fig. 4

Box A shows lifting of the posterior hyaloid from the retina with the vitrector on aspiration mode. The arrow points to the interface of the hyaloid and the retina. Box B shows ILM forceps used to peel the ILM above the white membrane (arrow denotes the edge of the flap). Box C shows a bent 30 gauge needle used to elevate the edge of the sub-ILM membrane. Box D shows the ILM forceps are used to peel the sub-ILM membrane off the retina.

Fig. 5

Histology of the sub-ILM fibrotic membrane with the hematoxylin and eosin stain shows a fibrocellular tissue that contains foci of pigmented cells (Box A, 400x). These pigmented cells stain positively with Perl's prussian blue stain (Box B, 400x), indicating presence of hemosiderin, as would be seen with hemorrhage. The specimen stained positively for collagen deposition with Masson trichrome (Box C, 400x). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)