Tip: Not every peripapillary hemorrhage is a sign for glaucoma

The Science behind the Tip

Most of the time, disc hemorrhages in patients with glaucoma are related to the disease itself. Although the strong association between disc hemorrhage and open-angle glaucoma (especially low-pressure glaucoma) was confirmed, most disc hemorrhages (70%),(1) were observed in participants without clear signs of glaucoma. This highlights the importance of identifying glaucomatous disc signs alongside a disc hemorrhage to accurately attribute the hemorrhage to glaucoma (1). “Glaucomatous” disc hemorrhages are usually flame-shaped and located adjacent to an area of a retinal nerve fiber layer defect. Frequently they are inferiorly in association with a notch. However, when the disc hemorrhage isn’t flame-shaped, is broader or not related to a specific RNFL defect, we must consider other causes (2,3,4). Non-glaucomatous disc hemorrhages can be linked to different conditions such as cardiovascular disease or a posterior vitreous detachment. A thorough anamnesis of the patient, including the patients’ medication, and the associated retinal findings must be considered, for example if the patient describes a new onset of floaters or has a history of migraines (5).

References

1. Mitchell P, Smith W, Chey T, Healey PR. Open-angle glaucoma and diabetes: the Blue Mountains eye study, Australia. Ophthalmology. 1997 Apr;104(4):712-8. doi: 10.1016/s0161-6420(97)30247-4.
2. Silva LO. Optic Disc Hemorrhage : What Next ? A glaucoma specialist shares how to manage patients with bleeding nerves. Review of Ophthalmology 2023 April 10 https://www.reviewofophthalmology.com/article/optic-disc-hemorrhage-what-next#:~:text=It's%20Not%20Always%20Glaucoma&text=Other%20causes%20of%20disc%20hemorrhage,medications%20such%20as%20blood%20thinners.
3. Jin C, Park GS, Kim KN, Song MY, Hwang YH. Comparison of posterior vitreous detachment-related and glaucomatous optic disc hemorrhage. Sci Rep. 2023 Mar 27;13(1):5011.
4. Ozturker ZK, Munro K, Gupta N. Optic disc hemorrhages in glaucoma and common clinical features. Can J Ophthalmol. 2017 Dec;52(6):583-591. https://pubmed.ncbi.nlm.nih.gov/29217027/
5. Grødum K, Heijl A, Bengtsson B. Optic disc hemorrhages and generalized vascular disease. J Glaucoma. 2002 Jun;11(3):226-30. https://pubmed.ncbi.nlm.nih.gov/12140400/

Contributors: Omar Hommayda MD FEBO, Rapperswil, Switzerland

Tip of the Month manager: Frances Meier-Gibbons
Tip of the Month editorial board: Francisco Goni, Karl Mercieca, Humma Shahid
Tip of the Month editors in chief: Manuele Michelessi, Francesco Oddone