The Disc Haemmorhage
Dr Shreya Jaiswal, Dr Prabhat Nangia, Dr Sarang Lambat, Dr Vinay Nangia
Suraj Eye Institute, 559 New Colony, Nagpur
A female, 79 years of age, presented with complaints of watering and blurring of vision in both eyes from past 1 month. She was a known case of systemic hypertension since 3 years. Best corrected visual acuity in right eye (OD) and left eye (OS) was 6/60, N10 and 6/36, N10 respectively. Anterior segment examination showed bilateral pseudophakia with posterior capsular opacification and pseudoexfoliation was noted at pupillary margin in OS. Intraocular pressure recorded by Goldmann applanation tonometer in OD was 20 mmHg and in OS was 24 mmHg.
Classically, disc haemorrhages associated with glaucoma are found mostly in the inferotemporal and superotemporal regions of the optic disc. Optic disc haemorrhage can be caused by ischaemic micro-infarction in the optic disc or by mechanical rupture of small blood vessels arising from structural changes at the level of the lamina cribrosa.
In this case there is asymmetry in the size of the cup and the neuroretinal rim, with the left eye cup being larger than the right Eye but there is no definitive notching and left eye neuroretinal rim is thinner as compared to the right eye. We would like to draw attention to the very small notches seen in figure 3 and figure 4 (red arrows) as being suggestive of small notches in the RNFL appearing at a very early stage and these would need to be watched. Even through early small notches may be hard to appreciate, they may often be early harbinger of glaucomatous damage. They should be correlated with clinical findings along the same meridian on the optic disc and parapapillary area for the retinal nerve fiber layer. They may also be followed up with the normal follow up of the glaucoma patient.
Optic disc haemorrhages are often associated with rim notching at the site of bleeding and also have been reported to correlate with and even predict the development of significant and progressive RNFL defects with their apex coinciding with the location of the disc haemorrhage. Disc haemorrhages may portend the appearance of neuroretinal rim loss, RNFL thinning and loss. While it may not be possible to detect any RNFL loss on the colour photograph, the RNFL thickness graphs may give a clue earlier on.
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Dr Vinay Nangia
MS, FRCS, FRCOphth
Suraj Eye Institute