Sir,

Dome-shaped posterior pole haemorrhages have been described in Terson syndrome (TS).1, 2 However, the exact location of these posterior pole haemorrhages have been unclear.3 Friedman et al2 showed that these haemorrhages are located beneath the internal limiting membrane (ILM) of the retina. The purpose of this report is to highlight the concurrent occurrence of a sub-ILM and subposterior hyaloid haemorrhage in TS producing a macular ‘double ring’ sign. We are unaware of any previous reports describing this sign and could find no reference to it in a computerized search utilizing the PubMed. Nd:YAG laser membranotomy of the ILM was successful in draining the sub-ILM haemorrhage and resorting the vision.

Case report

A 46-year-old female underwent endovascular coiling following a subarachnoid haemorrhage caused by a ruptured anterior communicating artery aneurysm. Following this, she complained of decreased vision in her left eye (LE). On ophthalmic evaluation, visual acuities were 6/6 right eye (RE) and counting fingers LE. Intraocular pressures and anterior segment examination were unremarkable. Fundus examination of the RE showed multiple scattered superficial and deep retinal haemorrhages involving the posterior pole (Figure 1a). The macula was normal. The LE showed a large dome-shaped macular sub-ILM haemorrhage characterized by a glistening light reflex and fine striae on the surface of the haemorrhage and a small dome-shaped subhyaloid haemorrhage located anterior and inferotemporal to the sub-ILM haemorrhage. These two haemorrhages caused a macular ‘double ring’ with the ‘inner ring’ presumably formed by the detached ILM and the ‘outer ring’ by the detached posterior hyaloid (Figure 1b).

Figure 1
figure 1

(a) The right fundus showing scattered superficial and deep retinal haemorrhages in the posterior pole. (b) The left fundus showing a dome-shaped sub-ILM haemorrhage (white asterix) and a subhyaloid haemorrhage located anterior and inferotemporal to the sub-ILM hemorrhage (orange asterix). Note the ‘double ring’ sign with the ‘inner ring’ caused by the sub-ILM bleed (blue arrows) and the ‘outer ring’ by the subhyaloid bleed (black arrows). (c) At 1 week postlaser photograph showing drainage of the sub-ILM blood into the vitreous (black arrows). Note the hazy view caused by the vitreous haemorrhage. (d) At 2 weeks postlaser photograph showing almost complete resolution of the sub-ILM haemorrhage. Note the subhyaloid pocket of blood remains unchanged (black arrow).

Full size image

Nd:YAG laser membranotomy of the ILM was performed with an argon laser, with the laser beam aimed at the lower most point of the sub-ILM haemorrhage, using a fundus contact lens and a pulse power starting at 2.0 mJ. At a power of 5.5 mJ, two small openings were created in the ILM. No immediate drainage of the blood was noted. At 1 week follow-up, there was evidence of the sub-ILM blood draining into the vitreous cavity (Figure 1c). At 2 weeks following the laser treatment, the vision improved from counting fingers to 6/12 with almost complete resolution of the sub-ILM haemorrhage. The small subhyaloid haemorrhage located inferotemporal to the macula was undrained (Figure 1d).

Comment

To our knowledge, this is the first report to document a sub-ILM and a subhyaloid haemorrhage occurring concurrently in TS, producing a macular ‘double ring’ sign. Literature is confusing regarding the exact anatomic location of dome-shaped haemorrhages in TS. Kuhn et al1 reported a 39% incidence of macular haemorrhages in TS and reported that blood accumulates beneath the ILM. Morris et al4 documented histologically the presence of a haemorrhage located between the ‘nerve fiber layer and the ILM’ but erroneously referred to it as ‘preretinal haemorrhage’. Recently, Friedman et al2 provided histological evidence that haemorrhage can be located posterior to the ILM in TS.

The most common site for a premacular haemorrhage is at the posterior pole, where the premacular bursa provides a potential space. Moreover, the ILM in the perimacular area is thinner with no attachment plaques between the ILM and the rest of the retina.5 A sudden intraocular haemorrhage in the setting of raised intracranial pressure can result in haemodissection of the ILM and the posterior hyaloid producing the macular ‘double ring’ (with the ‘inner ring’ caused by the sub-ILM haemorrhage and the ‘outer ring’ by the subhyaloid bleed). These rings may represent the demarcation line between the detached and the adherent ILM and posterior hyaloid, respectively.

In theory, blood could initially enter one compartment and percolate through to the other, or enter both compartments (sub-ILM and subhyaloid) simultaneously. We believe this case demonstrates that the latter explanation is more likely, as the subhyaloid haemorrhage remained unchanged following drainage of the sub-ILM haemorrhage. A macular ‘double ring’ sign can be a clinical indicator of a sub-ILM and subhyaloid haemorrhage occurring concurrently.