What is the management of Terson syndrome?

Management of Terson Syndrome

Terson syndrome requires immediate ophthalmological evaluation with indirect funduscopy in all patients with subarachnoid hemorrhage or acute intracranial pressure elevation, followed by either conservative observation for mild cases or pars plana vitrectomy for dense hemorrhages that impair vision or fail to resolve spontaneously. 1, 2

Initial Recognition and Diagnosis

Who to Screen

• All patients with subarachnoid hemorrhage should undergo ophthalmological screening, as Terson syndrome occurs in 8-21% of these patients 3, 1
• Patients with higher World Federation of Neurosurgical Societies (WFNS) grades and those experiencing seizures are at significantly increased risk and require priority screening 1
• Patients with traumatic brain injury and acute intracranial pressure elevation also warrant evaluation 2

Diagnostic Approach

• Perform indirect funduscopy as the primary screening tool to identify intraocular hemorrhage 1
• Document the type and location of hemorrhage: vitreous (66.7%), preretinal (66.7%), intraretinal (30%), or subretinal (13.3%) 2
• Obtain baseline best-corrected visual acuity (BCVA) immediately upon diagnosis 2
• Use B-mode ultrasound, CT, or MRI when funduscopy is limited by dense hemorrhage 4

Critical Timing Consideration

Delayed diagnosis directly correlates with worse visual outcomes - longer intervals between neurological event and ophthalmological diagnosis result in poorer final visual acuity 2. The mean detection time in recent series was 58 days after the neurological event, but earlier detection is associated with better prognosis 2.

Treatment Algorithm

Conservative Management (Observation)

Indicated for:

• Mild intraocular hemorrhages with preserved visual function 4
• Patients with baseline BCVA better than 0.20 logMAR 2
• Unilateral cases with good vision in the contralateral eye 4

Monitoring protocol:

• Serial ophthalmological examinations to assess for spontaneous resolution 2
• Approximately 40% of cases resolve spontaneously without intervention 2
• If no improvement occurs within the observation period, proceed to surgical intervention 4

Surgical Management (Pars Plana Vitrectomy)

Indicated for:

• Dense vitreous hemorrhage that obscures fundus visualization 2
• Bilateral intraocular hemorrhage (occurs in 87.5% of Terson syndrome cases) 2, 4
• Baseline BCVA worse than 1.84 logMAR 2
• Hemorrhage that fails to resolve spontaneously after observation period 4
• Cases where visual recovery is needed urgently for rehabilitation 3

Surgical outcomes:

• Vitrectomy results in significant visual improvement: mean preoperative BCVA of 0.03 improving to 0.76 postoperatively 1
• All surgically treated patients in recent series achieved significant improvement in visual function 1
• Complementary photocoagulation may be necessary in select cases 5

Timing of Intervention

In severe cases, ophthalmological treatment may need to precede intracranial neurosurgical procedures to preserve vision 5. The mortality rate from the underlying subarachnoid hemorrhage is not increased by Terson syndrome (15.4%), but morbidity is higher (42%) 5.

Clinical Pitfalls to Avoid

• Failure to screen systematically: Many patients with subarachnoid hemorrhage are not routinely evaluated for Terson syndrome despite its 21% incidence 1
• Delayed ophthalmological consultation: Physiatrists and neurologists may be the first to identify visual loss and must promptly coordinate ophthalmological evaluation 3
• Assuming spontaneous resolution will occur: While 40% resolve spontaneously, the remaining 60% require surgical intervention 2
• Underestimating visual prognosis: With appropriate treatment, visual outcomes are generally excellent, making timely intervention critical 1, 2

Prognostic Implications

Terson syndrome serves as a prognostic indicator for the severity of underlying subarachnoid hemorrhage - patients with higher Fisher and WFNS scores have significantly higher rates of Terson syndrome 1. The presence of Terson syndrome indicates more severe intracranial pathology and warrants aggressive management of both the neurological and ophthalmological complications 4.