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Unilateral vitreous haemorrhage secondary to caudal epidural injection: a variant of Terson's syndrome
  1. S Gibran,
  2. K Mirza,
  3. F Kinsella
  1. Eye Clinic, University College Hospital, Galway, Ireland
  1. Correspondence to: Dr Gibran; syedgibran{at}yahoo.com

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Terson's syndrome is characterised by vitreous haemorrhage accompanying subarachnoid or any other form of intracranial haemorrhage. Although Litten reported vitreous haemorrhage in association with subarachnoid haemorrhage in 1881, it was Terson who described the syndrome in 1900. Haemorrhage in Terson's syndrome may be contained between the internal limiting membrane and retina or extend into the vitreous cavity. Other findings include multiple preretinal, intraretinal, subretinal haemorrhages, as well as macular rings1 and epiretinal membranes.2

Case report

A 47 year old man with chronic back pain due to epidural adhesions (confirmed in magnetic resonance imaging (MRI)) was referred to the anaesthetic department for caudal epidural injection of steroids and saline to break up the epidural adhesions for pain relief. He received the injection through the sacral hiatus between the spinal dura and spinal canal in the caudal epidural space under general anaesthesia. Following recovery from general anaesthesia, he stated that he had lost the sight in his left eye. Ophthalmic examination at that time confirmed vision of 6/6 right eye and 6/60 left eye with no afferent pupillary defect, normal anterior segments, and the presence of a dense left vitreous haemorrhage with a normal right eye. There were no other predisposing factors for vitreous haemorrhage. Post-epidural MRI scan of brain and spinal cord was performed. There was no intracranial haemorrhage but the epidural adhesions were still noted to be present. The patient's vision gradually improved to 6/12 over a 3 year period but because of residual severe symptomatic floaters he underwent left pars plana vitrectomy, which allowed his vision to improve to 6/6 unaided.

Comment

Terson3 proposed that intraocular haemorrhage occurred secondary to intracranial hypertension, which resulted in elevated peripapillary capillary pressure. The most commonly cited mechanism is that elevated intracranial pressure4 resulting from subarachnoid haemorrhage is transmitted within the optic nerve sheath and obstructs intraocular venous drainage causing distension and rupture of peripapillary and retinal capillaries resulting in significant haemorrhage in the subhyaloid space or vitreous cavity.

In our patient during the caudal epidural injection the fluid wave of injection did not spread uniformly in the epidural space and break the adhesions but, instead, got trapped in tiny compartments formed by the adhesions and caused lateral pressure on the spinal cord, thus increasing subarachnoid space pressure, resulting in vitreous haemorrhage in the left eye (Fig 1).

Figure 1

Site of injection is shown by blue arrow, compartments formed by the adhesions shown by red markings.

Therefore, we feel the cases with pathogenesis of intraocular haemorrhage, secondary to a sudden rise of intracranial pressure, should be considered as the variant of Terson's syndrome.

The clinical course of Terson's syndrome is typically one of gradual resolution of the vitreous haemorrhage and return of normal vision. Haemorrhages that do not resolve may require vitrectomy, but several studies have proposed that early vitrectomy also may improve visual outcome.5

Indications for early pars plana vitrectomy6 include vitreous haemorrhage in infants (prevent amblyopia) and in adults with bilateral vitreous haemorrhage. Indications for conservative management include rapidly clearing vitreous haemorrhage, mild haemorrhage, unilateral cases with normal vision in the fellow eye, and pre-existing ocular damage precluding a favourable visual outcome.

References

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