Disc hemorrhage discovered in exam for subconjunctival hemorrhage

Issue: April 2012

ByJoseph Hallak, OD, PhD, FAAO

ByJoseph Bacotti, MD

A 70-year-old white male presented with a painless, red right eye. He was diagnosed with a 2+ subconjunctival hemorrhage nasally.

The patient reported a Valsalva maneuver the day before secondary to constipation. No previous occurrence was reported. Nonpreserved artificial tears were used as a palliative for comfort.

The visual acuity was 20/20 in each eye. IOPs were 18 mm Hg OD and 18 mm Hg OS in the mid-afternoon. The cup-to-disc ratios were 0.35 with sloping cups and myopic thinning/atrophy in both eyes, as seen in a nondilated fundus evaluation. All other findings were unremarkable.

The patient was diagnosed with a 2+ subconjunctival hemorrhage nasally.

The small disc hemorrhage superonasally in the left eye was evident.

Images: Hallak J

The patient’s medical history was unremarkable except for benign prostatic hyperplasia treated with oral finasteride once daily. The patient was also taking an over-the-counter omega-3 fatty acid, two 300-mg capsules per day (EPA and DHA) for the last year. There was no known allergy and no smoking or regular alcohol use reported. Of note is the patient’s family history of glaucoma. His mother has glaucoma and his sister is being treated aggressively for primary open-angle glaucoma with field loss and Drance hemorrhages.

A week later the patient was seen for follow-up. The subconjunctival hemorrhage was resolving; the IOPs were 22 mm Hg OD and 21 mm Hg OS at 8:30 a.m. Nondilated fundus evaluation using a Volk 90-D lens (Volk, Mentor, Ohio) revealed a small disc heme at the superonasal margin of the left eye through a 2-mm to 3-mm pupil.

The patient returned for a dilated fundus exam. The IOPs were 24 mm Hg OD and 23 mm Hg OS at 2:30 p.m.; the anterior chamber angles were considered open before dilation. The cup-to-disc ratio was estimated at 0.6 in the right eye with a prominent lamina cribrosa, a mild disc tilt and a conus temporally. The cup in the left eye was 0.6 vertical and 0.5 horizontal with a prominent lamina and a conus temporally. The conus appearance was consistent with moderate myopia.

The small disc hemorrhage superonasally in the left eye was evident. Other retinal findings were notable for benign drusen, peripheral lattice and paving stone degeneration, which are not uncommon in moderate myopia. There was grade 1 nuclear sclerosis in both eyes with a +1 posterior subcapsular cataract in the right eye. A few days later the disc hemorrhage took a “sea fan” appearance.

The subconjunctival hemorrhage recurred in the same position in the right eye and with the same intensity 2 weeks after the first episode and resolved in another week. Nonpreserved artificial tears were used for comfort. No Valsalva maneuver was reported at that time.

What is your diagnosis?

Disc hemorrhage

Subconjunctival hemorrhage can result from a Valsalva maneuver. If recurrent, we need to: rule out a conjunctival lesion and check the blood pressure, prothrombin time, CBC with platelet and C and S protein. If it is severe, we need to check for trauma. Anticoagulant therapy and nonsteroidal anti-inflammatory drugs can precipitate a subconjunctival hemorrhage or exacerbate it.

There was no history of trauma, the blood pressure was normal (120 mm Hg/70 mm Hg) and the blood tests were normal.

Bjerrum, in 1889, reported an association between optic disc hemorrhage and glaucomatous damage, a concept that was later picked up by Drance in 1969. Drance disc hemorrhage became a well established risk factor for glaucoma disease progression. Does our patient have glaucoma? Not all disc hemorrhages are a harbinger of glaucoma.

Many causes for disc hemorrhage

The differential diagnoses in the presence of disc hemorrhage include: posterior vitreous detachment, posterior vitreous traction, localized branch vein occlusion, hypertensive or diabetic retinopathy, bleeding disorder, disc edema, optic nerve drusen, choroidal neovascular membrane and nonglaucomatous optic nerve disease (i.e., ischemic) or a random (less than 0.2%) occurrence in normal eyes.

None of the above applied to our patient.

Retinal nerve fiber layer scans showed thinning corresponding to the nasal step in the visual fields.

However, there is a syndrome of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage. It is found in myopic fundi with disc tilt, Sibony and colleagues reported. The subretinal hemorrhage appears superonasally. It has an acute onset and lacks recurrence.

The possible causes are vitreous traction, disc edema and Valsalva maneuver triggering increased venous pressure. Random occurrence of disc hemorrhage in normals is rare and estimated at less than 0.2%.

Our patient fits into this last category.

Nineteen days later, the patient was tested on a Humphrey SITA Fast (Carl Zeiss Meditec, Dublin, Calif.) white-on-white visual field, which showed nasal steps in both eyes with a glaucoma hemifield test outside normal limits; the mean deviations were: -2.92 dB OD and -3.21 dB OS.

The patient was diagnosed with primary open-angle glaucoma and put on Xalatan (latanoprost 0.005%, Pfizer), one drop in each eye at bedtime. The target pressure should be reduced by 25% to 30%, that is, to 18 mm Hg.

The central corneal thickness measurements yielded above-average numbers (574 microns OD, 569 microns OS); gonioscopy showed a normal open angle 360 degrees.

OCT obtained to assist with diagnosis

Spectral domain OCT was obtained to further characterize the retinal status. Both eyes showed normal foveal contour, no neurosensory retinal thickening or cystoid change and no abnormalities at the level of the retinal pigment epithelium. Retinal nerve fiber layer scans showed thinning in all quadrants. Of note is the temporal thinning corresponding to the nasal step evident in the Humphrey Visual Field.

This Heidelberg Retinal Tomography indicates a large zone beta.


The SITA fast, taken with the Humphrey Visual Field, was taken at different dates and shows nasal step. The field is grossly stable and the mean deviation appears to be grossly stable, with a 0.05 dB and 0.14 dB change.

The Drance hemorrhage occurs in areas where nerve fibers are present, often adjacent to thinned areas where the nerve fibers are lost. According to some estimates, a well-trained professional can miss Drance hemorrhage in up to 84% of cases (according to one of the Ocular Hypertension Treatment Study analysis reports, Budenz et al.), which explains the widespread disparity in reported incidence of Drance hemorrhage from 2% to 40%. Drance hemorrhage does not necessarily mean glaucoma, but its presence in glaucoma or a glaucoma suspect is an indication for intervention.

Our patient showed zone beta parapapillary atrophy; zone beta may be associated with glaucoma. Parapapillary atrophy was considered as a common occurrence of a myopic conus. It is an atrophy of the retinal pigment epithelium and the choriocapillaris.

However, recent studies indicate that more Drance hemorrhages are present in eyes with large beta zones (Ahn et al., Radcliff et al.); the larger the zone, the more corresponding visual field loss (Anderson, Heijl and Samander); and an increase in the size of this beta zone foretells progression of glaucoma (Uchida et al.). Note the large beta zones shown in the Heidelberg Retina Tomography results.

Follow-up

At follow-up visits the visual field remained stable. Eleven months later, the patient’s IOPs in the morning and evening are 13 mm Hg OD and 14 mm Hg OS and 11 mm Hg OD and 12 mm Hg OS, taken by the same doctor.

The patient is J.H., one of the authors who learned a lesson the hard way. We always give advice but rarely heed our own; we rarely turn inward and take care of ourselves. All in all, early diagnosis and maintaining a steady level of target IOP are paramount.

References:

Ahn JK, Kang JH, Park KH. Correlation between a disc hemorrhage and peripapillary atrophy in glaucoma patients with a unilateral disc hemorrhage. J Glaucoma. 2004;13(1):9-14.

Anderson, DR. Correlation of the peripapillary anatomy with the disc damage and field abnormalities in glaucoma. Doc Ophthalmol Proc Ser. 1983;35:1-10.

Budenz DL, Anderson DR, Feuer WJ. Ocular Hypertension Treatment Study Group. Detection and prognostic significance of optic disc hemorrhages during the Ocular Hypertension Treatment Study. Ophthalmology. 2006;113(12):2137-2143.

Heijl A, Samander C. Peripapillary atrophy and glaucomatous visual field defects. Doc Ophthalmol Proc Ser. 1985;42:403-409.

Radcliff NM, Liebmann JM, Rozenbaum I, et al. Anatomic relationships between disc hemorrhage and parapapillary atrophy. Am J Ophthalmol. 2008;146:735-740.

Uchida H, Ugurlu S, Caprioli J. Increasing peripapillary atrophy is associated with progressive glaucoma. Ophthalmology. 1998;105(8):1541-1545.

For more information:

Joseph Hallak, OD, PhD, is in private practice in Hicksville, N.Y. He can be reached at 183 Broadway, #308, Hicksville, NY 11801; (516) 935-0717; drjhallak@aol.com.

Joseph Bacotti, MD, can be reached at 330 Old Country Road, Mineola, NY 11501; (516) 739-6600; drbacotti@optonline.net.

Disclosures: Dr. Bacotti and Dr. Hallak have no financial interests to disclose