Examine this patient's fundus.



· Sudden, painless loss of vision.

· Sudden appearance of floaters and black spots with or without flashing lights.

· History of stroke (subarachnoid haemorrhage).

· History of diabetes, retinal tears, vitreous detachment, retinal vein occlusion.

· History of trauma.


· A large, solitary subhyaloid haemorrhage (there may be no fluid level if the

patient is lying flat).

· There may be associated retinal haemorrhage.

· Twenty per cent have mild papilloedema.

Proceed as follows:

· Comment on any obvious hemiplegia.

Note. When the subhyaloid (preretinal) haemorrhage extends into the vitreous humour it

is called Terson's syndrome.


This hemiplegic patient has a subhyaloid haemorrhage (lesion) due to subarachnoid

haemorrhage (aetiology).


What is the commonest cause of subhyaloid haemorrhage? Subarachnoid haemorrhage

(BMJ 1990; 301:190).

What are the other causes of haemorrhage into the vitreous?

· Local injury.

· Blood diseases.

· Hypertension.

· Diabetes.

· Idiopathic.

Mention some causes of neck stiffness.

· Subarachnoid haemorrhage.

· Meningitis.

· Posterior fossa tumours.

· local neck pathology such as cervical spondylosis

What are causes of deterioration in a patient with subarachnoid haemorrhage ? ·


· Cerebral infarction due to reflex vasospasm of cerebral vessels (hence the

rationale to use nimodipine).

· Secondary hydrocephalus.

How would you investigate such a patient?

CT head scan, and if this rules out intracranial hypertension, then a lumbar puncture to

diagnose minor leaks.