INSTRUCTION Examine this patient's fundus. SALIENT FEATURES History · 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. Examination · 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. DIAGNOSIS This hemiplegic patient has a subhyaloid haemorrhage (lesion) due to subarachnoid haemorrhage (aetiology). ADVANCED-LEVEL QUESTIONS 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 ? · Rebleeds. · 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.