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Introduction: Terson syndrome (TS) is defined as any intraocular haemorrhage identified in patients with acute intracranial pathology. TS appears to be associated with clinical severity in patients with subarachnoid haemorrhage (SAH), but the association is yet to be defined in patients with traumatic brain injury (TBI) and intracerebral haemorrhage (ICH). This study aimed to evaluate the diagnostic performance of ocular ultrasound (OU) and its usefulness in clinical practice., Material and Methods: We performed an observational, prospective, single-centre study of neurocritical care patients. We analysed cases and controls, defined according to indirect ophthalmoscopy (IO) and OU findings. We determined the diagnostic characteristics of OU. A multivariate analysis was performed to identify clinically relevant associations., Results: The sample included 91 patients diagnosed with ICH (41.76%), SAH (29.67%), and TBI (28.57%). TS was identified by OU in 8 patients (8.79%) and by IO in 24 (24.37%). The adjusted mortality rate in patients with TS showed an odds ratio (OR) of 4.15 (95% confidence interval [CI], 1.52-11.33). All patients with TS detected by OU presented Glasgow Coma Scale scores < 9, with an elevated risk of needing decompressive craniectomy (OR: 9.84; 95% CI, 1.64-59). OU presented an overall sensitivity of 30.43%, specificity of 98.53%, and diagnostic accuracy of 81.32%. For the detection of vitreous haemorrhage, sensitivity and specificity were 87.5% and 98.5%, respectively., Conclusions: OU diagnosis of TS identifies extremely critical patients, who may require the highest level of care; TS is an independent risk factor for in-hospital mortality., (Copyright © 2020 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.)

A 47-year-old man presented with profound loss of vision in right eye and relative afferent pupillary defect. On fundus examination, posterior pole details were obscured due to dense vitreous haemorrhage. B-scan ultrasonography was performed that revealed a mushroom-shaped hyperechoic lesion with medium internal reflectivity on A-scan ultrasonography. After performing contrast-enhanced MRI of the orbit, a diagnosis of choroidal melanoma was established. Patient was managed using plaque brachytherapy based on multiplanar MRI. This was followed 10 months later by pars plana vitrectomy and cataract extraction. Vision postoperatively improved to 20/60. A systematic clinical assessment along with supportive ancillary investigations augments diagnostic accuracy and reduces delay in definitive management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: There are no conflicts of interest

Importance: Ocular symptoms represent approximately 2% to 3% of all emergency department (ED) visits. These disease processes may progress to permanent vision loss if not diagnosed and treated quickly. Use of ocular point-of-care ultrasonography (POCUS) may be effective for early and accurate detection of ocular disease., Objective: To perform a large-scale, multicenter study to determine the utility of POCUS for diagnosing retinal detachment, vitreous hemorrhage, and vitreous detachment in the ED., Design, Setting, and Participants: A prospective diagnostic study was conducted at 2 academic EDs and 2 county hospital EDs from February 3, 2016, to April 30, 2018. Patients who were eligible for inclusion were older than 18 years; were English- or Spanish-speaking; presented to the ED with ocular symptoms with concern for retinal detachment, vitreous hemorrhage, or vitreous detachment; and underwent an ophthalmologic consultation that included POCUS. Patients with ocular trauma or suspicion for globe rupture were excluded. The accuracy of the ultrasonographic diagnosis was compared with the criterion standard of the final diagnosis of an ophthalmologist who was masked to the POCUS findings. Seventy-five unique emergency medicine attending physicians, resident physicians, and physician assistants performed ocular ultrasonography., Exposure: Point-of-care ultrasonography performed by an emergency medicine attending physician, resident physician, or physician assistant., Main Outcomes and Measures: Sensitivity and specificity of POCUS in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment in patients presenting to the ED with ocular symptoms., Results: Two hundred twenty-five patients were enrolled. Of these, the mean age was 51 years (range, 18-91 years) and 135 (60.0%) were men; ophthalmologists diagnosed 47 (20.8%) with retinal detachment, 54 (24.0%) with vitreous hemorrhage, and 34 (15.1%) with vitreous detachment. Point-of-care ultrasonography had an overall sensitivity of 96.9% (95% CI, 80.6%-99.6%) and specificity of 88.1% (95% CI, 81.8%-92.4%) for diagnosis of retinal detachment. For diagnosis of vitreous hemorrhage, the sensitivity of POCUS was 81.9% (95% CI, 63.0%-92.4%) and specificity was 82.3% (95% CI, 75.4%-87.5%). For vitreous detachment, the sensitivity was 42.5% (95% CI, 24.7%-62.4%) and specificity was 96.0% (95% CI, 91.2%-98.2%)., Conclusions and Relevance: These findings suggest that emergency medicine practitioners can use POCUS to accurately identify retinal detachment, vitreous hemorrhage, and vitreous detachment. Point-of-care ultrasonography is not intended to replace the role of the ophthalmologist for definitive diagnosis of these conditions, but it may serve as an adjunct to help emergency medicine practitioners improve care for patients with ocular symptoms.

Competing Interests: Competing interests: None declared.

Competing Interests: There are no conflicts of interest

Point of care ultrasound in the emergency department (ED) is increasingly being used to diagnose time-sensitive, vision-threatening conditions. We present a case of a 64-year-old female who presented to the ED with a three-day history of worsening left eye floaters. Point of care ocular ultrasound demonstrated a posterior chamber containing many echogenic opacities of varying size without acoustic shadowing. Movement of the eye resulted in significant after-movement of these opacities, giving the classic "washing machine" appearance seen with vitreous hemorrhage (VH). Based on these ultrasound findings, the patient was diagnosed with a VH and was referred to ophthalmology. The consulting ophthalmologist ultimately diagnosed the patient with asteroid hyalosis without VH. Asteroid hyalosis is a benign condition of the vitreous resulting in calcium phosphate and lipid deposits that can mimic more serious VH on point of care ultrasound. Knowledge of this mimic is helpful for communication with specialists and for awareness of the potential for misdiagnosis with ocular ultrasound.

Terson's syndrome describes the concurrence of intracranial hemorrhage, vitreous hemorrhage and juxtapapillary subinternal limiting membrane and retinal hemorrhage. In most cases, the retinal and vitreous hemorrhage will clear spontaneously. Vitrectomy was indicated by persistent hemorrhage in two cases. Ultrasound was used to follow up the changes including premacular hemorrhage that appeared as a dome-shaped, smooth, mildly elevated, immobile membrane overlying the posterior pole. This membrane which represents the posterior hyaloid or internal limiting membrane is usually highly reflective due to the submembranous blood adherent to its posterior surface. Consequently, it may mimic localized detachment of the posterior pole. Differentiation from retinal detachment can usually be made by considering the history and other clinical findings. The clinical manifestations of Terson's syndrome, correlated well with the ultrasound findings until vitrectomy was done.

A case of bilateral persistent hyperplastic primary vitreous (PHPV) in a 3-month-old male infant, who had bilateral leukokoria, is presented. The child was referred for imaging with a clinical suspicion of retinoblastoma. Gray-scale ultrasound evaluation revealed an echogenic band in the posterior segment of both globes, extending from the posterior surface of the lens capsule to the optic disc. Doppler examination revealed the presence of arterial flow in the band in both globes. Associated echogenic hemorrhage was also seen, which was confirmed by computed tomography. Most cases of PHPV are sporadic and unilateral, and bilateral PHPV is rare. The imaging features in this case suggest the diagnosis of bilateral PHPV and differentiate it from retinoblastoma. This entity, although infrequent, should be considered in the differential diagnosis while evaluating bilateral leukokoria.

A 53-year-old man presented with an acute headache and mental status changes due to rupture of an anterior choroidal artery aneurysm. A preoperative CT scan demonstrated subarachnoid hemorrhage, bilateral optic nerve sheath hemorrhage, and bilateral intraocular hemorrhage. Ophthalmoscopy and B-scan ocular ultrasound disclosed vitreous hemorrhages, features consistent with Terson syndrome. This is the first CT report of Terson syndrome showing bilateral optic nerve sheath hemorrhage.

A 61-year-old male initially presented to the ophthalmology department complaining of sudden visual loss. Fundus photography and ultrasonography followed by computed tomography identified Terson's syndrome caused by subarachnoid hemorrhage (SAH). Cerebral angiography revealed a dissecting aneurysm of the left vertebral artery. Other than obtunded visual acuity, his neurological examination was normal and he denied any headache. He was treated conservatively with pain and blood pressure control. He complained of headache associated with rerupture of the aneurysm on day 5. The patient died of rerupture on day 14. The clinical course of this patient indicates that Terson's syndrome may occur without sudden increase of intracranial pressure. Terson's syndrome may occur as a rare initial clinical sign of SAH caused by ruptured cerebral aneurysm.

Aim: We undertook a national survey to establish the management of dense vitreous haemorrhage without obvious cause., Methods Design: Cross-sectional anonymous self-reporting survey of ophthalmic practitioners within three target groups: vitreoretinal specialists (VRS), nonvitreoretinal specialists (NVRS), and associate specialists (AS)., Intervention: Presentation of the hypothetical scenario of a patient presenting with recent onset (fresh) vitreous haemorrhage with no retinal view and no apparent cause on history taken at presentation., Outcome Measures: The relative importance assigned by respondents to eight examination techniques at presentation. The proportion of respondents stating that they would review patients and perform B-scan examination at or prior to 2 weeks after presentation. The stated time to surgical intervention by VRS, and the time to referral by NVRS and AS., Results: VRS ranked B-scan examination higher than AS (P<0.001). A total of 98.1% of VRS indicated that they would next review patients within 2 weeks of presentation, this figure fell to 86.5% for NVRS and 47% for AS (P<0.001). A 98.1% of VRS indicated that they would next perform B-scan ultrasound within 2 weeks of presentation, this figure fell to 88.9% for NVRS and 70.6% for AS (P<0.001). The mean time to surgical intervention by VRS was 9.5 weeks without retinal tear demonstrated on B-scan, 1.7 weeks with retinal tear demonstrated on B-scan and 1 week with retinal detachment demonstrated on B-scan. The mean time to referral by NVRS was 6.7 weeks and by AS was 11.9 weeks., Conclusions: Vitreoretinal specialists considered B-scan the most important examination tool, and typically perform B-scan early and frequently after presentation. Non-VR ophthalmologists (particularly associate specialists) review patients and perform B-scan ultrasound later and less often than vitreoretinal specialists. We recommend early referral to VR specialists, as reported referral even in uncomplicated cases would often be outside the timeframe within which VR specialists would typically choose to operate.

Air-bags have received widespread support as an effective means of enhancing automotive safety, and they are becoming more common as standard automobile equipment on many cars. Although air-bag induced ocular injuries are rare, they present a serious concern because of the possibility of permanent damage or visual impairment. To date, most reports have investigated ocular injury from high velocity motor vehicle accidents and reports of ocular injury from low speed motor vehicle accidents have been rare. We describe a patient who sustained severe ocular injury, including periorbital fracture, hyphema, vitreous hemorrhage, and choroidal rupture of the macular area, due to an inflated air-bag in a low speed motor vehicle accident.

Purpose: To ascertain the causes of vitreous hemorrhage and to determine the accuracy of ultrasound (U/S) in these cases, based on the degree of agreement between ultrasound and clinical findings., Methods: A chart review of 96 consecutive patients (106 eyes) with dense vitreous hemorrhage who underwent A- and B-scan U/S by one examiner between June 1996 and June 1999. U/S records were evaluated to determine the presence and exact distribution of areas of retinal detachment and the presence of posterior vitreous detachment, retinal tear, intraocular foreign body, or choroidal detachment. Clinical information was obtained from the medical records after the vitreous hemorrhage was reabsorbed or following vitreous surgery. Clinical and U/S findings were compared. False-positive and False-negative rates for U/S were calculated based on clinical findings., Results: In 37 eyes (35%) the vitreous hemorrhage was because of proliferative diabetic retinopathy and in 33 eyes (31%) because of ocular trauma. The false-positive rate for retinal detachment (retinal detachment by U/S without clinical confirmation) was 18.9% (seven of 37 eyes). Retinal tears were diagnosed and localized accurately in only four of nine eyes (44%)., Conclusions: The most common cause of vitreous hemorrhage was proliferative diabetic retinopathy, followed by ocular trauma. U/S correctly diagnosed all cases of retinal detachment, but less than 50% of retinal tears. A total of 18.9% of the eyes were falsely diagnosed as having retinal detachment. U/S is an effective diagnostic tool in patients with vitreous hemorrhage.

Purpose: To discuss and possibly explain the ultrasonic lighthouse effect, a metaphor suggested for an artifact-like phenomenon sometimes found by B-scan in eyes having had intra-ocular perfluorocarbon and/or silicone oil injected as part of vitreoretinal surgery., Method: Analysis of the ultrasonic findings with a view to the specific gravities of the above injected substances. Compared to water, perfluorocarbon has a higher and silicone oil a lower gravity; they are heavy and light, respectively., Results: The elicited lighthouse effect may appear localized or 'mobile'. When evoked only from specific positions on the globe, most likely it is explained by a lens-like accumulation of material trapped at the vitreous base just under the transducer. When mobile it depends on head position; there is a gravitational shift in position of the material, as evident in particular when becoming visible in the anterior chamber., Conclusions: In case reports in literature slit-lamp verified anterior segment perfluorocarbon remnants have caused acoustic disturbances of a similar nature. In this study we found evidence that also silicone oil can underlie the acoustic lighthouse effect.

Methods: 40 cases of vitreous haemorrhage secondary to Eales' disease were taken up for vitrectomy. Depending upon duration of vitreous haemorrhage patients were divided into two groups: Group I (20 eyes) - early vitrectomy group with duration between 3-6 months; Group II (20 eyes) - deferred vitrectomy group with duration of more than 6 months. All patients were followed up for a minimum period of 3 months following vitrectomy., Results: Eyes in Group I showing a preoperative ultrasonic picture of complete posterior vitreous detachment, less mobility of organised vitreous haemorrhage and mid vitreous organisation on kinetic echography achieved a final visual acuity of 6/9 or better in 13 (65%) eyes as compared to 4 (20%) eyes in Group II (p<0.01). Poor visual outcome in the deferred group was secondary to cystoid macular oedema, macular scar, macular pucker formation and macular degeneration., Conclusion: Improved visual outcome in the early vitrectomy group was probably because the haemorrhagic blood and its toxic products had less time to damage the macula, a lesser incidence of macular traction and cystoid macular oedema.

Purpose: Terson syndrome may be overlooked in the acute setting and often requires ophthalmologic intervention to prevent long-term visual loss. In this syndrome, vitreous or retinal hemorrhage results from an abrupt rise in intracranial pressure, leading to retinal venous hypertension and intraocular hemorrhage. Our objective was to determine whether imaging findings could be discovered that might facilitate an earlier diagnosis., Methods: Our inpatient medical record data base for 1991-1996 listed 11 patients with Terson syndrome. The medical records of these 11 patients were reviewed retrospectively and compared with their noncontrast head CT scans and with scans of 10 control subjects. One additional case was discovered prospectively, for a total of 12 patients. Three radiologists unaware of the patients' history evaluated CT scans of the orbits for evidence of intraocular hemorrhage., Results: CT findings in eight patients were suggestive of retinal hemorrhage manifested by a retinal crescent or nodule that was slightly hyperdense relative to the vitreous humor. There was a high degree of concordance between the retrospective and independent reviews., Conclusion: Retinal nodularity and crescentic hyperdensities are evident on CT scans in the majority of patients with Terson syndrome. Although findings are subtle and not present in all cases, in the setting of subarachnoid hemorrhage they suggest retinal hemorrhage and warrant detailed fundoscopic evaluation.

Vitreous haemorrhage is an unusual presenting feature of malignant melanoma of the choroid. We describe three cases in which this occurred. The three tumours shared a number of common features: all were located in the peripheral choroid, were of a similar size and had a small herniation of tumour tissue through Bruch's membrane. We believe that vascular congestion caused by constriction of the tumour vasculature at the site of herniation is the most probable cause for the haemorrhage in these cases. We review the relevant literature and discuss some of the commoner differential diagnoses.

Pre-vitrectomy errors in diagnostic A & B mode ultrasound may result in affection of the surgical outcome. We have done a retrospective analysis of fifty patients who were screened by both A & B mode echography and analyzed the data which revealed that real-time kinetic echography is required for accurate interpretation of the vitreoretinal status. Besides, quantitative A scan examination also has fallacies due to the echo beam not striking the sclerochoroid complex at right angles, and a modification of this technique is suggested. Lastly old retinal detachments may not produce echo-patterns diagnostic of retinal detachments resulting in fallacious interpretation. We recommend that combined A mode and real time B-mode and often repeat echography is essential for accuracy in diagnosis.