Management of Terson Syndrome: Long-Term Experience in a Single Center

Abstract

Background/objectives: Terson Syndrome (TS) is a rare entity consisting of an intraocular hemorrhage secondary to subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (IH). This study aimed to retrospectively describe the experience of the Ophthalmology Unit of Policlinico Gemelli, Rome, in the management of TS.

Methods: Twenty-four eyes of 19 patients (10 males-53%; 9 females-47%; mean age of 44.73 ± 12.49 years) with TS who had pars plana vitrectomy between 2011 and 2024 were included. The primary outcome was the mean change in best-corrected visual acuity (BCVA) 1-3 months after surgery. The secondary outcome was the correlation of post-operative BCVA with the timing of vitrectomy (early vs. late, ≤100 or >100 days).

Results: The time between diagnosis and surgery ranged from 33 to 284 days (median = 102 days, interquartile range IQR = 74-161). Baseline BCVA ranged from 6 to 50 ETDRS letters with a median of 17 letters (IQR = 15-25) and significantly increased after surgery, with a median value of 80 (IQR = 70-85). The BCVA percentage improvement had a median of 325% (IQR = 300-431%). No differences in post-operative BCVA were found between patients who underwent early or late vitrectomy. One vitrectomy was complicated by an endophthalmitis.

Conclusions: Although no clear guidelines exist on managing TS, vitrectomy significantly improves BCVA, and a delay in surgical intervention does not necessarily worsen the functional outcome. However, an early vitrectomy could improve the stimuli perception, facilitating the rehabilitation process.

Keywords: Terson Syndrome; intraocular hemorrhage; subarachnoid hemorrhage; vitrectomy; vitreous hemorrhage.

Figure 1

B-scan ultrasonography of a case of Terson Syndrome (a). Pre-operative fundus photograph (b, top) showing a vitreous hemorrhage anterior to the optic disc and pre-operative macular scan (b, bottom). One-month post-operative fundus photograph (c, top) and OCT macular scan (c, bottom).

Figure 2

Pre-operative fundus photograph (a), post-operative fundus photograph (b), and OCT macular scan (c).

Figure 3

Pre-operative fundus photograph (a, top) and OCT macular scan (a, bottom) of the case 12-RE. Fundus photograph (b, top) and OCT macular scan (b, bottom) showing a post-operative endophthalmitis. Multiple fundus photographs showing diffuse dot-blot hemorrhages and silicon oil in the vitreous cavity (c, top) after 25 G vitrectomy for endophthalmitis. OCT macular scan (c, bottom) showing a substantially preserved macular anatomy, with evidence of silicon oil in the vitreous cavity.

Figure 4

(A) Sunburst plot illustrating the primary causes of intraocular hemorrhage within the inner circle and detailing the arterial locations or regions involved in subarachnoid hemorrhage (SAH) in the outer circle. (B) Visualization of changes in best-corrected visual acuity (BCVA) from pre- vitrectomy (blue dots) to post-vitrectomy (red dots) for each patient, with dashed lines connecting pre- and post-surgery values to highlight individual changes. (C) Correlation matrix employing Spearman’s coefficients to analyze the relationships among patient age, time delay to surgery, and BCVA changes before and after surgery. Asterisks (*) denote statistically significant correlations (p < 0.05). (D) Alluvial plot showing the timing of surgical intervention (early vs. late) linked to patient outcomes, categorized by treatment response into ‘good responders’ (those whose BCVA improvement was greater than or equal to the median increase of 325%) and ‘poor responders’ (those below this threshold). The plot also distinguishes the surgical gauge used, noting whether it was smaller or equal to 25 G, to explore the impact of instrument size on surgical outcomes.