Bilateral Terson syndrome in an adult following ventriculoperitoneal shunt dysfunction

Shruti Kochar; Sumeet Lahane; Dhaivat Shah; Neeraj Israni; Rwituja Thomas

doi:10.4103/ijo.IJO_2043_22

Users Online: 1138

PHOTO ESSAY

Year : 2023 | Volume : 3 | Issue : 2 | Page : 574-575

Bilateral Terson syndrome in an adult following ventriculoperitoneal shunt dysfunction

Shruti Kochar¹, Sumeet Lahane², Dhaivat Shah³, Neeraj Israni⁴, Rwituja Thomas⁵
¹ Department of Ophthalmology, CHL Hospitals, Indore, Madhya Pradesh, India
² Department of Ophthalmology, Sir JJ Hospital, Mumbai, Maharashtra, India
³ Department of Vitreoretina, Choithram Nethralaya, Indore, Madhya Pradesh, India
⁴ Department of Cataract and Refractive Surgery, Innovision Eye Hospital and Laser Centre, Navi Mumbai, Maharashtra, India
⁵ Department of Oculoplasty and Ocular Oncology, Vision Eye Centres, New Delhi, India

Date of Submission	18-Aug-2022
Date of Acceptance	30-Jan-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Rwituja Thomas
Vision Eye Centre, 19, Siri Fort Road, New Delhi - 110 049
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2043_22

Abstract

Keywords: Hydrocephalus, Terson syndrome, ventriculoperitoneal

How to cite this article:
Kochar S, Lahane S, Shah D, Israni N, Thomas R. Bilateral Terson syndrome in an adult following ventriculoperitoneal shunt dysfunction. Indian J Ophthalmol Case Rep 2023;3:574-5

How to cite this URL:
Kochar S, Lahane S, Shah D, Israni N, Thomas R. Bilateral Terson syndrome in an adult following ventriculoperitoneal shunt dysfunction. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 5];3:574-5. Available from: https://www.ijoreports.in/text.asp?2023/3/2/574/374928

Terson syndrome is the development of intraretinal, subretinal, subhyaloid, or vitreous hemorrhages following an episode of acute intracranial hypertension.^[1] This condition has most commonly been described in the setting of trauma, intracranial aneurysms, tumors, and iatrogenically raised intracranial pressure (ICP).^[2] It commonly occurs in adults but can rarely take place in children with vascular anomalies.^[3] Ventriculoperitoneal (VP) shunt dysfunction can cause field changes due to papilledema or decreased vision due to optic atrophy following chronic papilledema.^[4]

A 39-year-old male presented with complaints of headache, blurring of vision, and double vision since 3 weeks. He had a history of having undergone a VP shunt placement 36 years prior for obstructive hydrocephalus secondary to aqueductal stenosis. Magnetic resonance imaging (MRI) of the brain showed a well-placed VP shunt tube [Figure 1]a and dilated bilateral lateral and third ventricles, implying shunt blockage [Figure 1]b. A thin hypointense membrane was seen in the posterior part of the aqueduct, indicating aqueductal obstruction. He had the best-corrected vision of 20/20 in the right eye and 20/40 in the left eye. Fundus examination of both eyes revealed extensive preretinal and subretinal hemorrhages [Figure 1]c and [Figure 1]d. The hematological workup was normal and, thus, ruled out anemic retinopathy and systemic infection. Lumbar puncture showed raised cerebrospinal fluid (CSF) pressure >30 cm. He subsequently underwent an endoscopic third ventriculostomy (ETV) to restore the flow of CSF, and the dysfunctional shunt was removed. He had an excellent postoperative neurological outcome with improvement in ICP. The retinal hemorrhages were self-limiting.

Figure 1: (a) MRI brain T1 axial image suggestive of dilated ventricles, VP shunt is noted within the ventricles. (b) Sagittal T2-weighted image showing position of VP shunt. (c) Right eye fundus photograph showing multiple pre- and subretinal hemorrhages at the posterior pole. (d) Left eye fundus photograph showing more extensive hemorrhages with involvement of the fovea

Click here to view

Discussion

At present, there is one case report of Terson syndrome following ETV, highlighting the role of raised ICP without intracranial hemorrhage.^[5] In our case, retinal changes occurred prior to the revision procedure, implicating shunt dysfunction as the causative factor.

To the best of our knowledge, this is the first report of bilateral retinal hemorrhages following VP shunt dysfunction.

Acknowledgement

Dr. Pranav Ghodgaonkar, Department of Neurosurgery, CHL Hospitals, Indore, MP, India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Kumaria A, Gruener AM, Dow GR, Smith SJ, Macarthur DC, Ingale HA. An explanation for Terson syndrome at last: The glymphatic reflux theory. J Neurol 2022;269:1264-71.
2.	Moraru A, Mihailovici R, Costin D, Brănişteanu D. Terson's syndrome – case report. Rom J Ophthalmol 2017;61:44-8.
3.	Bhardwaj G, Jacobs MB, Moran KT, Tan K. Terson syndrome with ipsilateral severe hemorrhagic retinopathy in a 7-month-old child. J AAPOS 2010;14:441-3.
4.	Oyama H, Hattori K, Kito A, Maki H, Noda T, Wada K. Visual disturbance following shunt malfunction in a patient with congenital hydrocephalus: —Case report—. Neurol Med Chir (Tokyo) 2012;52:835-8.
5.	Hoving EW, Rahmani M, Los LI, Renardel de Lavalette VW. Bilateral retinal hemorrhage after endoscopic third ventriculostomy: Iatrogenic Terson syndrome: Case report. J Neurosurg 2009;110:858-60.