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• W2116752820 abstract "Dr. Mills suggests that it was we who expanded the original definition of Terson syndrome from vitreous hemorrhage caused by subarachnoid hemorrhage to that caused by subdural hemorrhage. Subdural bleeding, however, has long been described by several authors to cause vitreous hemorrhage, even if it is indeed less commonly identified as the type of intracranial hemorrhage leading to Terson syndrome.1Clarkson J.G. Flynn Jr, H.W. Daily M.J. Vitrectomy in Terson’s syndrome.Am J Ophthalmol. 1980; 90: 549-552Abstract Full Text PDF PubMed Scopus (39) Google Scholar, 2Gutierrez Diaz A. Jimenez Carmena J. Ruano Martin F. et al.Intraocular hemorrhage in sudden increased intracranial pressure (Terson syndrome).Ophthalmologica. 1979; 179: 173-176Crossref PubMed Scopus (20) Google Scholar, 3Shaw Jr, H.E. Landers III, M.B. Vitreous hemorrhage after intracranial hemorrhage.Am J Ophthalmol. 1975; 80: 207-213Abstract Full Text PDF PubMed Scopus (55) Google Scholar Since the clinical implications for the ophthalmologist are very similar, regardless of the underlying cause of the vitreous hemorrhage in patients with Terson syndrome, it would be an error to narrow the definition to those cases caused by subarachnoid hemorrhage.The second problem with Dr. Mills’ approach is his misinterpretation of our original case reports. We never used the term “shaken baby syndrome,” nor did we even suggest that the ocular findings in our cases were the result of the children having been shaken. All four children in our study sustained massive direct head trauma. For instance, one of the babies (Case #26, described in our article as “child abuse”) was savagely hit; he developed a skull fracture and a subdural hemorrhage that had to be removed surgically. Another child (Case #17) also underwent neurosurgery to have the subdural blood removed.There are numerous reports in the literature about babies having been “battered” or “abused” with consequent subdural and then vitreous hemorrhages (Terson syndrome).4Greenwald M.J. Weiss A. Oesterle C.S. Friendly D.S. Traumatic retinoschisis in battered babies.Ophthalmology. 1986; 93: 618-625Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 5Riffenburgh R.S. Sathyavagiswaran L. Ocular findings at autopsy of child abuse victims.Ophthalmology. 1991; 98: 1519-1524Abstract Full Text PDF PubMed Scopus (56) Google Scholar These babies had clinical pictures identical to those seen in our cases, including the hemorrhagic macular cysts that we described earlier.6Morris R. Kuhn F. Witherspoon C.D. et al.Hemorrhagic macular cysts in Terson’s syndrome and its implications for macular surgery.Dev Ophthalmol. 1997; 29: 44-54Crossref PubMed Scopus (29) Google Scholar Shaking is obviously not the only method of inflicting harm on children. Furthermore, the adults who present with vitreous hemorrhage after subdural hemorrhage also sustain direct head trauma rather than having been shaken.7Keithahn M.A. Bennett S.R. Cameron D. Mieler W.F. Retinal folds in Terson syndrome.Ophthalmology. 1993; 100: 1187-1190Abstract Full Text PDF PubMed Scopus (41) Google Scholar Therefore, a clear distinction between ocular complications suffered due to shaking versus those caused by more direct trauma must be made.Our greatest concern regarding Dr. Mills’ management principle is his disagreement with, and indeed refusal of, our suggestion that early vitrectomy in the infants is needed to possibly prevent amblyopia. While we did caution that the clinician should not expect as complete a visual recovery in the child as in an adult because of concomitant brain damage, it would contradict the physician’s basic principles to deny someone a proven treatment on the assumption that it may not achieve its goal. There are numerous case reports showing that spontaneous resorption of the intravitreal blood in Terson syndrome may take years; that serious complications (retinal detachment, proliferative vitreoretinopathy, etc.) may arise from not performing vitrectomy; and that early removal of hemorrhagic macular cysts, present in over one-third of eyes, is especially important (the reader is referred to our original article for references). Furthermore, while we admitted that amblyopia is unlikely to be the only factor responsible for incomplete visual recovery in these babies, we have reason to believe that it is a contributory factor. Early removal of the media opacity, such as vitreous hemorrhage, is widely recommended to prevent amblyopia (Preferred Practice Pattern, Amblyopia, American Academy of Ophthalmology, 1997; p. 18). A reader who takes the time to read our Table 1 will notice that while two children were too young to have their preoperative and postoperative visions tested, improvement was achieved in both eyes in Case 1, and that amblyopia has developed in Case 17, in whom no vitrectomy was performed (incidentally, the vitreous hemorrhage did not spontaneously resorb in this child in 2 years). Limited improvement was achieved once the vitreous hemorrhage was removed. The clinician has to wonder whether further improvement could not have been possible with early vitrectomy.Amblyopia, it must be also emphasized, is just one of the unique complications threatening the infant’s eye with persistent vitreous hemorrhage; others include myopia up to 12 diopters and strabismus.8Miller-Meeks M.J. Bennett S.R. Keech R.V. Blodi C.F. Myopia induced by vitreous hemorrhage.Am J Ophthalmol. 1990; 109: 199-203Abstract Full Text PDF PubMed Scopus (59) Google ScholarIn summary, we strongly believe that it would be a mistake to exclude subdural hemorrhage as a cause of Terson syndrome; to believe that shaking, rather than direct head trauma, is responsible for most cases of Terson syndrome in infants; and a grave error not to offer early vitrectomy for nonresolving vitreous hemorrhage in children with Terson syndrome just because concomitant brain damage may limit the extent of visual improvement. Dr. Mills suggests that it was we who expanded the original definition of Terson syndrome from vitreous hemorrhage caused by subarachnoid hemorrhage to that caused by subdural hemorrhage. Subdural bleeding, however, has long been described by several authors to cause vitreous hemorrhage, even if it is indeed less commonly identified as the type of intracranial hemorrhage leading to Terson syndrome.1Clarkson J.G. Flynn Jr, H.W. Daily M.J. Vitrectomy in Terson’s syndrome.Am J Ophthalmol. 1980; 90: 549-552Abstract Full Text PDF PubMed Scopus (39) Google Scholar, 2Gutierrez Diaz A. Jimenez Carmena J. Ruano Martin F. et al.Intraocular hemorrhage in sudden increased intracranial pressure (Terson syndrome).Ophthalmologica. 1979; 179: 173-176Crossref PubMed Scopus (20) Google Scholar, 3Shaw Jr, H.E. Landers III, M.B. Vitreous hemorrhage after intracranial hemorrhage.Am J Ophthalmol. 1975; 80: 207-213Abstract Full Text PDF PubMed Scopus (55) Google Scholar Since the clinical implications for the ophthalmologist are very similar, regardless of the underlying cause of the vitreous hemorrhage in patients with Terson syndrome, it would be an error to narrow the definition to those cases caused by subarachnoid hemorrhage. The second problem with Dr. Mills’ approach is his misinterpretation of our original case reports. We never used the term “shaken baby syndrome,” nor did we even suggest that the ocular findings in our cases were the result of the children having been shaken. All four children in our study sustained massive direct head trauma. For instance, one of the babies (Case #26, described in our article as “child abuse”) was savagely hit; he developed a skull fracture and a subdural hemorrhage that had to be removed surgically. Another child (Case #17) also underwent neurosurgery to have the subdural blood removed. There are numerous reports in the literature about babies having been “battered” or “abused” with consequent subdural and then vitreous hemorrhages (Terson syndrome).4Greenwald M.J. Weiss A. Oesterle C.S. Friendly D.S. Traumatic retinoschisis in battered babies.Ophthalmology. 1986; 93: 618-625Abstract Full Text PDF PubMed Scopus (150) Google Scholar, 5Riffenburgh R.S. Sathyavagiswaran L. Ocular findings at autopsy of child abuse victims.Ophthalmology. 1991; 98: 1519-1524Abstract Full Text PDF PubMed Scopus (56) Google Scholar These babies had clinical pictures identical to those seen in our cases, including the hemorrhagic macular cysts that we described earlier.6Morris R. Kuhn F. Witherspoon C.D. et al.Hemorrhagic macular cysts in Terson’s syndrome and its implications for macular surgery.Dev Ophthalmol. 1997; 29: 44-54Crossref PubMed Scopus (29) Google Scholar Shaking is obviously not the only method of inflicting harm on children. Furthermore, the adults who present with vitreous hemorrhage after subdural hemorrhage also sustain direct head trauma rather than having been shaken.7Keithahn M.A. Bennett S.R. Cameron D. Mieler W.F. Retinal folds in Terson syndrome.Ophthalmology. 1993; 100: 1187-1190Abstract Full Text PDF PubMed Scopus (41) Google Scholar Therefore, a clear distinction between ocular complications suffered due to shaking versus those caused by more direct trauma must be made. Our greatest concern regarding Dr. Mills’ management principle is his disagreement with, and indeed refusal of, our suggestion that early vitrectomy in the infants is needed to possibly prevent amblyopia. While we did caution that the clinician should not expect as complete a visual recovery in the child as in an adult because of concomitant brain damage, it would contradict the physician’s basic principles to deny someone a proven treatment on the assumption that it may not achieve its goal. There are numerous case reports showing that spontaneous resorption of the intravitreal blood in Terson syndrome may take years; that serious complications (retinal detachment, proliferative vitreoretinopathy, etc.) may arise from not performing vitrectomy; and that early removal of hemorrhagic macular cysts, present in over one-third of eyes, is especially important (the reader is referred to our original article for references). Furthermore, while we admitted that amblyopia is unlikely to be the only factor responsible for incomplete visual recovery in these babies, we have reason to believe that it is a contributory factor. Early removal of the media opacity, such as vitreous hemorrhage, is widely recommended to prevent amblyopia (Preferred Practice Pattern, Amblyopia, American Academy of Ophthalmology, 1997; p. 18). A reader who takes the time to read our Table 1 will notice that while two children were too young to have their preoperative and postoperative visions tested, improvement was achieved in both eyes in Case 1, and that amblyopia has developed in Case 17, in whom no vitrectomy was performed (incidentally, the vitreous hemorrhage did not spontaneously resorb in this child in 2 years). Limited improvement was achieved once the vitreous hemorrhage was removed. The clinician has to wonder whether further improvement could not have been possible with early vitrectomy. Amblyopia, it must be also emphasized, is just one of the unique complications threatening the infant’s eye with persistent vitreous hemorrhage; others include myopia up to 12 diopters and strabismus.8Miller-Meeks M.J. Bennett S.R. Keech R.V. Blodi C.F. Myopia induced by vitreous hemorrhage.Am J Ophthalmol. 1990; 109: 199-203Abstract Full Text PDF PubMed Scopus (59) Google Scholar In summary, we strongly believe that it would be a mistake to exclude subdural hemorrhage as a cause of Terson syndrome; to believe that shaking, rather than direct head trauma, is responsible for most cases of Terson syndrome in infants; and a grave error not to offer early vitrectomy for nonresolving vitreous hemorrhage in children with Terson syndrome just because concomitant brain damage may limit the extent of visual improvement." @default.
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• W2116752820 title "Terson syndrome: Authors’ reply" @default.
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