FLORetina 2025: Using multimodal imaging to rethink Terson syndrome

Researchers and clinicians gathered to explore cutting-edge developments in retinal imaging at the FLORetina 2025–International Congress on OCT and OCT Angiography (ICOOR), held from 4 to 7 December in Florence, Italy.¹

Among the presentations was new work revisiting the multimodal imaging characteristics of Terson syndrome. Priyanka Sanghi, BSc, MSc, MBBS, of the Medical Retina Service at Moorfields Eye Hospital NHS Foundation Trust in London, shared updated insights into how emerging imaging techniques—particularly fundus autofluorescence and optical coherence tomography (OCT)—may reshape the understanding of the disease’s evolution and its long-term retinal consequences.

In this Q&A, the Eye Care Network caught up with Sanghi to learn more about how different imaging modalities contribute to diagnostic clarity, what multimodal findings reveal about chronic retinal changes, and how these insights might influence future clinical pathways, including artificial intelligence (AI)-assisted detection and collaborative research.

Editor's note: Transcript edited lightly for clarity and length.

Modern Retina: Which imaging modalities provide the most diagnostic clarity for Terson syndrome?

Priyanka Sanghi, BSc, MSc, MBBS: In the acute setting, color widefield imaging and OCT provide the most diagnostic clarity. Color widefield imaging helps to document the extent and distribution of multi-layered hemorrhages, whilst OCT defines the depth of hemorrhage and then allows assessment of the outer retina as the hemorrhage clears.

Where our work adds something new is in the chronic phase. We are seeing persistent, nummular areas of hypoautofluorescence that can remain for years after the initial neurological event, even when the OCT looks relatively normal. These lesions may be the only imaging sign of previous Terson syndrome.

MR: How do multimodal findings refine our understanding of disease progression?

Sanghi: Multimodal imaging has shown us that the evolution of Terson syndrome is more complex than perhaps previously appreciated. OCT suggests that many eyes achieve substantial outer retinal recovery over time, but in our cohort almost half still exhibited ellipsoid zone attenuation and/or outer nuclear layer thinning at final follow-up.

Fundus autofluorescence (FAF) adds a different dimension. The striking hypoautofluorescent lesions we see are often far more extensive than the structural changes seen on OCT, and many occur in regions where the OCT appears relatively normal. They appear to occur independently of previous hemorrhage, and the mismatch with OCT suggests that the hypoautofluorescent changes may represent residual injury or alternatively reflect subtle metabolic retinal pigment epithelium dysfunction that is not detectable on structural OCT.

In some eyes, these FAF abnormalities become the only lasting “footprint” of Terson syndrome, revealing disease activity we would miss if we relied solely on OCT and/or clinical examination. This highlights the need to image more eyes with Terson syndrome with fundus autofluorescence to determine whether consistent phenotypes emerge and glean further insights into the underlying pathogenesis of the condition.

MR: Were there any surprising correlations between imaging biomarkers and clinical severity?

Sanghi: There was a lack of a definitive correlation between structural imaging and clinical severity; many eyes with preserved visual acuity and a relatively normal OCT still demonstrated persistent nummular hypoautofluorescent lesions. Conversely, not all areas of subtle outer retinal thinning on OCT had corresponding hypoautofluorescent changes. This suggests that the processes contributing to long-term retinal change in Terson syndrome may be more diffuse than previously assumed, rather than solely a mechanical injury related to the transient rise in intracranial pressure. It reinforces the value of multimodal imaging in this condition, as no single modality captures the full spectrum of pathology.

MR: How might these insights influence surgical timing or intervention strategies?

Sanghi: Our findings do not imply that the threshold or timing for vitrectomy should change on the basis of autofluorescence alone, but they do prompt us to reconsider what constitutes “recovery” in Terson syndrome. Traditionally, surgical timing is guided by the density and location of hemorrhage, visual acuity, and the patient’s neurological status.

The presence of widespread hypoautofluorescent changes suggests more diffuse or metabolic stress than is visible on structural imaging, reinforcing the value of multimodal imaging follow-up in these patients. It also raises the question of whether earlier clearance of hemorrhage could reduce long-term sequelae, which would require prospective, multicenter evaluation.

MR: Do you foresee AI-assisted imaging playing a role in early detection?

Sanghi: Yes, I do think AI has potential in this space. In the acute phase of Terson syndrome, patients are often critically unwell, may not be able to report visual symptoms, and imaging may be challenging. AI tools could assist in classifying the different planes of hemorrhage and support earlier detection, and they may even help identify prognostic markers on fundal appearance that relate to the underlying head injury.

In the chronic phase, AI could be utilized to detect the nummular, hypoautofluorescent lesions we are observing more consistently, quantify their extent, and perhaps identify patterns we may not appreciate clinically. Of course, Terson syndrome is relatively uncommon, so meaningful AI development would require large, multicenter datasets. This is where collaborative networks become essential.

MR: What’s the most pressing question you hope FLORetina will help answer for you?

Sanghi: This is my first time attending FLORetina and I am really looking forward to learning about the latest advances in my field, particularly developments in imaging technology and how we can use these to identify subtle biomarkers and follow patients more effectively over time. FLORetina brings together such a broad range of expertise, and I feel seeing how different centers approach similar clinical questions will be extremely valuable. I hope to gain a deeper understanding of how emerging imaging tools can redefine our diagnostic pathways and help us to interpret findings that are beyond the limits of standard imaging.

Priyanka Sanghi, BSc, MSc, MBBS
E: Priyanka.sanghi3@nhs.net
Sanghi is with the Medical Retina Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.

REFERENCE:

1. Sanghi P. Revisiting imaging findings of Terson syndrome with multimodal imaging. Presented at: FLORetina 2025–International Congress on OCT and OCT Angiography (ICOOR); December 4-7, 2025; Florence, Italy.