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Sir

Vitreous haemorrhage secondary to subarachnoid haemorrhage was first described by Terson1 in 1900. We report an unusual case of pseudo-Terson's syndrome presenting to Stoke Mandeville Hospital's Eye Casualty with bilateral spontaneous vitreous haemorrhages and occipital headache.

Case report

A 57-year-old man presented to the eye casualty with an acute onset of bilateral blurred vision, photopsia, associated with sudden onset of occipital headache, tinnitus, and fever. Nausea was the predominant symptom with no vomiting, neck stiffness, or neurological complaints. He was hypertensive, on atenolol and amitriptyline.

He was fully alert and oriented. Examination revealed a visual acuity of 6/9 in the right eye and 6/60 in the left eye. Retinal examination was obscured because of vitreous haemorrhage in both eyes. A provisional diagnosis of bilateral vitreous haemorrhage secondary to subarachnoid haemorrhage (Terson's syndrome) was made. A full neurological assessment excluded signs of meningeal irritation or neurological deficit. CT scan of the brain showed high signal in the superior sagittal sinus; however, it was reported as normal. Absence of an increased intracranial pressure and red blood cells or xanthocromia on lumbar puncture excluded subarachnoid haemorrhage. B-scan of orbits revealed dense vitreous haemorrhage in both eyes. Systematic survey of each of the eye's four quadrants did not show evidence of small retinal tears or rhegmatogenous retinal detachment in the peripheral fundi. Full blood count, biochemical profile, clotting profile, and electrocardiogram were all normal. Blood pressure was 141/95. MRI of the brain was reported normal.

Vitreous haemorrhage cleared rapidly by day 3 in both eyes. Ocular examination showed a horseshoe retinal tear with minimal subretinal fluid in the right superotemporal quadrant and a suspicious area in the left superotemporal quadrant. Right retinal detachment repair was performed together with cryotherapy to the left eye.

After 1 week later, examination revealed a second horseshoe retinal tear with local subretinal fluid in the right inferotemporal retinal quadrant and three horseshoe retinal tears and bullous retinal detachment in the left superotemporal quadrant. Neither macula was affected by retinal detachment. Visual acuity recovered to 6/12 in the right eye and 6/6 in the left eye. Vitrectomy and fluid–gas exchange repair of the left retinal detachment and a second explant for the right eye were carried out.

Comment

Rhegmatogenous retinal detachment has a strong bilateral tendency. It results from chronic degenerative process, wherein both eyes are involved. The incidence of bilateral retinal detachment is 10% in normal population and 16% in aphakic patients.2 However, simultaneous retinal detachment of both eyes is a rare finding. An annual incidence of 0.35 patients with bilateral simultaneous retinal detachment per 100 000 populations was estimated recently in Norway.3 These patients were significantly younger. They are usually myopic with multiple round retinal holes.4

Unilateral and bilateral retinal or vitreous haemorrhages are common features secondary to subarachnoid haemorrhage. They occur in 3–5% of cases of subarachnoid haemorrhages5 and usually come to the attention of an ophthalmologist during recovery after the patient regains consciousness. Any patient presenting with retinal or vitreous haemorrhages associated with neurological symptoms such as headache, nausea, or altered consciousness should be investigated to exclude intracranial haemorrhages; however, bilateral vitreous haemorrhages and headache are not pathognomonic of Terson's syndrome. A non-diabetic vitreous haemorrhage most frequently arises as a result of vitreous separation. Our case demonstrates the importance of careful inspection as vitreous haemorrhage clears together with ultrasound B-scan to exclude rhegmatogenous retinal detachment even when the cause of vitreous haemorrhage is not considered to be related to vitreous separation.