Tissue damage in the eye stained by bleeding is known as corneal blood staining, which is directly associated with hyphema.1 The damage is a result of the seepage of hemoglobin or hemosiderin into the corneal stroma. To our knowledge, to date there has been no case report of a posterior lens capsule stained by a vitreous hemorrhage, even though the posterior capsule of lens is anatomically adjacent to the anterior vitreous. We report a video-documented case in which blood staining of the posterior capsule was observed during combined phacovitrectomy in a patient with Terson syndrome.
A 49-year-old man reported the sudden onset of a severe headache and episodes of unconsciousness. After being admitted to our emergency hospital, he was diagnosed with a subarachnoid hemorrhage resulting from a right vertebral artery dissection and immediately received stent-assisted coil embolization treatment. After the treatment, he recovered consciousness but had bilateral visual loss. He was subsequently referred to the ophthalmology section of the hospital. On examination, the visual acuity was hand motion and a slitlamp examination showed a cortical cataract in both eyes. The patient had a long history of atopic dermatitis; thus, the cataracts were determined to be atopic. Fundoscopic examinations showed a severe vitreous hemorrhage in both eyes that made it impossible to see the fundi. B-scan ultrasonography indicated no sign of retinal detachment, and electroretinograms showed normal waveforms. These ophthalmologic findings were consistent with a diagnosis of Terson syndrome.
The patient's general condition was deemed satisfactory by the 25th day in the hospital. A 25-gauge pars plana vitrectomy was performed in the right eye after phacoemulsification with intraocular lens implantation; all procedures were uneventful. During the vitrectomy procedure, there was no hemorrhage in the posterior precortical vitreous pocket under the microsurgical scope (Video 1). Although the vitreous hemorrhage was removed enough, the operative field was very hazy. There was no contamination between the contact lens and the cornea and no hyphema in the anterior chamber. Although the residual lens cortex and anterior vitreous on the posterior capsule were removed, the haze did not resolve. Moreover, a small transparent circle approximately 1.0 mm in diameter, the presumed basement of Cloquet canal, was observed in the center of the cloudy operative field (Figure 1). It was concluded that the posterior capsule had been stained by the vitreous hemorrhage. Therefore, a posterior capsulotomy was performed around the small circle, which resulted in a clear operative field (Video 2). Surgery was continued without further complications.
On the patient's 27th day in the hospital, the same surgery was performed in patient's left eye. The posterior capsule was clear, and surgery could be performed without the creation of a posterior capsulotomy.
Many case reports describe vitreous hemorrhage occurring concurrently with or after subarachnoid hemorrhage, a condition known as Terson syndrome.2–7 However, to our knowledge, no case report focused on the blood staining of the posterior capsule produced by this syndrome. We cannot be certain why the posterior capsule was stained in our case. One possible reason is that the posterior capsule in this patient was directly exposed to the acute dense bleeding in the vitreous and the surface of the posterior capsule was damaged with hemoglobin or hemosiderin deposit. The barrier function of the posterior capsule to the outer material might have decreased because of the atopic cataract.
In our case, a small transparent circular space in the center of the posterior capsule blood staining was observed. We are confident that this was the basement of Cloquet canal. Cloquet canal is formed from the tubular shrinkage of the primary vitreous at 12 weeks gestation, and its basement is anatomically adjacent to the posterior lens capsule via Wieger ligament. Swept-source optical coherence tomography performed by Itakura et al.8,9 indicated that the posterior precortical vitreous pocket, which is a boat-shaped premacular liquefied space, has a connecting channel to Cloquet canal. Our patient had no hemorrhage in the posterior precortical vitreous pocket. Therefore, Cloquet canal of our patient might not be involved with blood staining in Terson syndrome with vitreous hemorrhage.
In conclusion, blood staining of the posterior capsule should be considered when the operative field is still hazy even after an efficient core vitrectomy is performed for severe vitreous hemorrhage.
None of the authors has a financial or proprietary interest in any material or method mentioned.
Brodrick JD. Corneal blood staining after hyphaema. Br J Ophthalmol 1972; 56:589-593
Terson A. De l'hémorrhagie dans le corps vitre au cours de l'hémorrhagie cerebrale. Clin Ophthalmol 1900; 6:309-312
Shinoda J, Iwamura M, Iwai T, Iwata T, Hattori T, Kondo H, Shikinami A, Funakoshi T, Sakai N, Yamada H. [Intraocular hemorrhage in ruptured intracranial aneurysm. Clinical study of 172 cases and reference to Terson's syndrome] [Japanese]. Neurol Med Chir (Tokyo) 1983; 23:349-354
Frizzell RT, Kuhn F, Morris R, Quinn C, Fisher WS III. Screening for ocular hemorrhages in patients with ruptured cerebral aneurysms: a prospective study of 99 patients. Neurosurgery 1997; 41:529-533; discussion by HH Batjer, DL Barrow, AA Sadun, 533-534
Kuhn F, Morris R, Witherspoon CD, Mester V. Terson syndrome. Results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid hemorrhage. Ophthalmology 1998; 105:472-477
Stiebel-Kalish H, Turtel LS, Kupersmith MJ. The natural history of nontraumatic subarachnoid hemorrhage-related intraocular hemorrhages. Retina 2004; 24:36-40
Skevas C, Czorlich P, Knospe V, Stemplewitz B, Richard G, Westphal M, Regelsberger J, Wagenfeld L. Terson's syndrome—rate and surgical approach in patients with subarachnoid hemorrhage; a prospective interdisciplinary study. Ophthalmology 2014; 121:1628-1633
Itakura H, Kishi S, Li D, Akiyama H. Observation of posterior precortical vitreous pocket using swept-source optical coherence tomography. Invest Ophthalmol Vis Sci 2013; 54:3102-3107
Itakura H, Kishi S, Li D, Akiyama H. En face imaging of posterior precortical vitreous pockets using swept-source optical coherence tomography. Invest Ophthalmol Vis Sci 2015; 56:2898-2900