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A blinding headache and two black eyes
  1. NICHOLAS D LAWN,
  2. EELCO F M WIJDICKS,
  3. BRIAN R YOUNGE
  1. Department of Neurology (Neurological-Neurosurgical Intensive Care Unit, Saint Mary’s Hospital), and Ophthalmology, Mayo Medical Center, Rochester, MN, USA
  1. Dr E F M Wijdicks, Department of Neurology (W8A), Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Telephone 001 507 284 5443; fax 001 507 284 4795; emailwijde{at}mayo.edu

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A 54 year old farmer, while bailing hay, recalled a sudden headache, “as if struck by lightening” before he lost consciousness. Brain CT showed widespread subarachnoid and intraventricular blood and acute obstructive hydrocephalus (figure top row).

The visual acuity was limited to detection of motion in both eyes. The red reflex and pupillary responses were absent. The posterior pole of the eye could not be visualised due to extensive vitreous haemorrhage. (Figure middle row: absent red reflex with appearance of “black pupils” after maximal dilatation; bottom row: red reflex in a normal subject for comparison.)

Retinal haemorrhage in subarachnoid haemorrhage may rupture the hyaloid membrane to enter the vitreous compartment (Terson’s syndrome).1 2 Although the prognosis for spontaneous visual recovery is good, vitrectomy should be considered in those patients with bilateral vitreous haemorrhage who have not improved after 6 to 12 months.3

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