Optic Disc Hemorrhages
Overview
Optic disc hemorrhages have relatively high specificity but relatively low sensitivity for glaucoma.1 These disc hemorrhages can be easily missed in routine clinical examinations,2 have proven to be an important risk factor for the development of glaucoma in patients with ocular hypertension,2 are a risk factor for glaucoma progression in patients who have already developed glaucoma,3,4 and are a significant predictor for visual field loss5 with a faster rate of visual field progression.6 Even on a cellular level, there is evidence to suggest that eyes with glaucoma with disc hemorrhages have a faster rate of retinal ganglion cell loss than eyes with glaucoma that do not have disc hemorrhages.7
Intraocular pressure reduction can help slow glaucomatous progression following disc hemorrhages.8
Pearls
High specificity:
Normal population: 0% to 1.4%
Disc hemorrhages are rarely found in normal eyes.
Other optic nerve diseases can have disc hemorrhages:
Posterior vitreous detachment, optic disc drusen, retinal vascular occlusive diseases, and systemic conditions (diabetes, hypertension, leukemia, systemic lupus erythematous).
Low sensitivity:
Ocular hypertension/glaucoma: 2% to 33.4%.
Disc hemorrhages are not found in all patients with ocular hypertension or glaucoma.
Not a reliable biomarker in screening for glaucoma.
Less frequent in patients with juvenile-onset primary open-angle glaucoma (POAG), age-related atrophic POAG, and highly myopic POAG.
Primary angle-closure prevalence: 0.5% to 5.7%.
All prevalence estimates are more likely a fraction of the total of all disc hemorrhages.
Frequency increases in the early stages of glaucoma to moderate glaucoma and then decreases with advanced stages of glaucoma.
In early glaucoma, glaucomatous disc hemorrhages are usually located in the inferior temporal and superior temporal disc sectors and do not occur in advanced glaucoma in disc sectors where the neuroretinal rim is absent.1
Detection can be more frequent by more careful clinical examinations and stereoscopic disc photos.
Appearance:
Splinter-shaped/flame-shaped hemorrhages usually located at the border of, and perpendicular to, the optic disc.
Usually thin in appearance.
Flame- or fan-shaped; more likely if abundant vascular extravasation.
Can be located within the optic disc tissue (laminar or prelaminar due to laminar pore tissue remodeling and common in myopic eyes), on the neuroretinal rim, or in the parapapillary zone.
Usually located more in the inferior temporal and/or superior temporal areas of the optic disc.
Parapapillary disc hemorrhages are more likely associated with retinal nerve fiber layer (RNFL) defects and neuroretinal rim thinning.
Shape consistent with the orientation of the (RNFL) axons.
Duration:
Visible for 8 days to 12 weeks after the initial bleeding.
Duration of glaucomatous disc hemorrhage may be associated with intraocular pressure.1
Higher intraocular pressure (IOP) may limit the extent of extravasation, resulting in smaller disc hemorrhages with potentially more rapid resolution and perhaps relatively lower perceived incidence.
Lower IOP may not limit the extent of extravasation, resulting in larger disc hemorrhages with potentially slower resolution and perhaps relatively higher perceived incidence.
Glaucomatous disc hemorrhages are most often observed in glaucoma patients with lower IOP (two to five times as much) than those with higher IOP.
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