Bedside optical coherence tomography for Terson’s syndrome screening in acute subarachnoid hemorrhage: a pilot study

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OBJECTIVE

Approximately 10% of patients with subarachnoid hemorrhage (SAH) become permanently, legally blind. The average cost of lifetime support and unpaid taxes for each blind person amounts to approximately $900,000. This study evaluates the feasibility and potential role of bedside optical coherence tomography (OCT) in Terson’s syndrome (TS) in patients with acute SAH (aSAH) and its potential role in blindness prevention.

METHODS

The authors conducted an open-label pilot study, in which 31 patients with an angiographic diagnosis of aSAH were first screened for TS with dilated funduscopy and then with OCT in the acute phase and at 6-week follow-up visits. Outpatient mood assessments (Patient Health Questionnaire–depression module, Hamilton Depression Scale), and quality of life general (NIH Patient-Reported Outcomes Measurement Information System) and visual scales (25-item National Eye Institute Visual Functioning Questionnaire) were measured at 1 and 6 weeks after discharge. Exclusion criteria included current or previous history of severe cataracts, severe diabetic retinopathy, severe macular degeneration, or glaucoma.

RESULTS

OCT identified 7 patients with TS, i.e., a 22.6% incidence in our aSAH sample: 7 in the acute phase, including a large retinal detachment that was initially missed by funduscopy and diagnosed by OCT in follow-up clinic. Dilated retinal funduscopy significantly failed to detect TS in 4 (57.1%) of these 7 cases. Intraventricular hemorrhage was significantly more common in TS cases (85.7% vs 25%). None of the participants experienced any complications from OCT examinations. Neither decreased quality of life visual scale scores nor a depressed mood correlated with objective OCT pathological findings at the 6-week follow-up after discharge. There were no significant mood differences between TS cases and controls.

CONCLUSIONS

OCT is the gold standard in retinal disease diagnosis. This pilot study shows that bedside OCT examination is feasible in aSAH. In this series, OCT was a safe procedure that enhanced TS detection by decreasing false-negative/inconclusive funduscopic examinations. It allows early diagnosis of macular holes and severe retinal detachments, which require acute surgical therapy to prevent legal blindness. In addition, OCT aids in ruling out potential false-positive visual deficits in individuals with a depressed mood at follow-up.

ABBREVIATIONS aSAH = acute SAH; GCS = Glasgow Coma Scale; H&H = Hunt and Hess; HDS = Hamilton Depression Scale; ILM = inner limiting membrane; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; NIH-PROMIS = NIH Patient-Reported Outcomes Measurement Information System; OCT = optical coherence tomography; PHQ-9 = Patient Health Questionnaire–depression module; SAH = subarachnoid hemorrhage; TS = Terson’s syndrome; VFQ-25 = 25-item National Eye Institute Visual Functioning Questionnaire.

Article Information

Correspondence Ciro Ramos-Estebanez: Case Western Reserve University, Cleveland, OH. cramoses@icloud.com.

INCLUDE WHEN CITING Published online February 2, 2018; DOI: 10.3171/2017.7.JNS171302.

C. Ramos-Estebanez and M. Kohen share first authorship of this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    OCT images of mild TS (case 1). A: Retinal image with hyporeflective areas representing shadows of blood remnants (rectangle). B: Follow-up a month later confirmed TS resolution with intact anatomy (rectangle). GCL = ganglion cell layer; INL = internal nuclear layer; IPL = internal plexiform layer; IS-OS = photoreceptor inner segment–outer segment junction; ONL = outer nuclear layer; OPL = outer plexiform layer; PHM = posterior hyaloid membrane; RNFL = retinal nerve fiber layer; RPE = retinal pigment epithelium.

  • View in gallery

    OCT images of severe TS. A: Subhyaloid and retinal sub-ILM bleeds (case 2). B: Severe TS with large retinal detachment (case 5). C: Severe TS with large retinal hemorrhage (rectangles) and macular hole (case 6).

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