Traumatic “TERSON SYNDROME PLUS”: Pneumocephalocele with optic atrophy

Introduction. Terson Syndrome is subarachnoid hemorrhage (SAH) with sub retinal hemorrhage flowing through channel. Reduced vision in such fresh case is due to hemorrhage itself, blocking macula/other photo receptors in the long run macular cellophane retinopathy which causes profound visual loss. SAH causes neurological problems which can become a risk factor for evacuating blood from vitreous. Hypertension is commonest cause to cause Terson Syndrome, but trauma is also devastating cause as it can lead to irreversible visual consequences like total loss of perception of light or blindness. Aim. Here we describe a case of Terson Syndrome plus disease features SAH in frontal lobe. Description of the case. When there is traumatic pneumocephalocele, it gives space to blood to imbibe towards bony optic canal and form hematoma around nerve sheath which causes compression around the same and leads to optic atrophy. Optic nerve can be injured by direct traumatic dissection during road traffic accidents (RTA), but even without that blood may accumulate around optic nerve and in turn leads to formation of hematoma and subsequently pressure induced optic atrophy. Moreover, blood can slowly travel to sub hyaloid space/sub retinal space (beneath internal limiting membrane or sub ILM) with probable gliosis covering typical boat shaped blood as seen in this case. This sub ILM hemorrhage or gliosis may have resolved through three injections of Triamcinolone in the orbital floor (OFTA) near apex, but optic atrophy snatches vision. This protocol was followed to treat traumatic compressive (peri optic hematoma) optic neuropathy and traumatic retinopathy associated with sub hyaloid hemorrhage. Conclusion. Diagnosis of Terson syndrome plus disease was established by addressing all features on computed tomography (CT) scan and magnetic resonance imaging (MRI). Plus, features include pneumocephalus, optic nerve sheath hematoma, optic atrophy and gliosis over sub-hyaloid hemorrhage, typical boat shaped. The part of hemorrhage still endured as seen on optical coherence topography, but vision was lost by virtue of optic atrophy. OCT shows clot in sub hyaloid space.