Spark ImageWise 13 – Glaucoma

The Disc Haemmorhage

Dr Shreya Jaiswal, Dr Prabhat Nangia, Dr Sarang Lambat, Dr Vinay Nangia 
Suraj Eye Institute, 559 New Colony, Nagpur 

Case Description
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. 

Figure 1 shows fundus photograph of right eye disc with vertical cup to disc ratio (VCDR) of 0.4:1, healthy neuroretinal rim, a disc haemorrhage located inferotemporally (yellow arrow) associated with the presence of temporal parapapillary atrophy (green arrow). There is presence of significant tessellation around the disc.
Figure 2 shows fundus photograph of examination of left eye disc with a VCDR of 0.5:1 and slightly pale neuroretinal rim. There is presence of superotemporal and inferotemporal optic disc haemorrhage (yellow arrows) along with the parapapillary atrophy (green arrow).
Figure 3 and 4 are retinal nerve fiber layer thickness map of right eye and left eye respectively, which shows normal RNFL thickness with a sudden dip noted in inferotemporal sector (notch, red arrow)

Discussion

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.

ReadWise

  1. Lee EJ, Han JC, Kee C. A novel hypothesis for the pathogenesis of glaucomatous disc hemorrhage. Progress in retinal and eye research. 2017 Sep 1;60:20-43. https://doi.org/10.1016/j.preteyeres.2017.08.002
  2. Sugiyama K, Uchida H, Tomita G, Sato Y, Iwase A, Kitazawa Y. Localized wedge-shaped defects of retinal nerve fiber layer and disc hemorrhage in glaucoma. Ophthalmology. 1999 Sep 1;106(9):1762-7.https://doi.org/10.1016/S0161-6420(99)90347-0
  3. Airaksinen PJ, Mustonen E,  Alanko HI. Optic disc haemorrhages precede retinal nerve fibre layer defects in ocular hypertension. Acta ophthalmologica. 1981 Oct;59(5):627-41. https://doi.org/10.1111/j.1755-3768.1981.tb08728.x
  4. Kim YK, Park KH. Lamina cribrosa defects in eyes with glaucomatous disc haemorrhage. Acta ophthalmologica. 2016 Sep;94(6):e468-73. https://doi.org/10.1111/aos.12903

Correspondence 

Dr Vinay Nangia
MS, FRCS, FRCOphth
Director 
Suraj Eye Institute
Nagpur
Email –education@surajeye.org

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