What is the alternative name for a splinter hemorrhage at the optic disc margin in glaucoma?

Drance hemorrhage A small flame-shaped or splinter hemorrhage at or near the disc margin in glaucoma is known as a Drance hemorrhage.

Where does a glaucomatous optic disc hemorrhage lie, and how is it oriented?

In the superficial nerve fibre layer, radial to the nerve fibres The hemorrhage sits in the superficial nerve fibre layer or at the border of the neuroretinal rim and runs radially along the course of the nerve fibres.

Deep in the choroid, spreading circumferentially

Beneath the retinal pigment epithelium, in a dome shape

Within the vitreous cavity, layered inferiorly

In which disc sectors are glaucomatous optic disc hemorrhages most often found?

Inferotemporal and superotemporal These hemorrhages cluster inferotemporally and superotemporally, the regions where early glaucomatous damage typically occurs.

Directly nasal to the disc centre

How long does a glaucomatous optic disc hemorrhage usually take to resolve?

Weeks to a few months The bleed clears over weeks to a few months, which is why a disc photograph is needed to document it before it disappears.

It persists permanently once formed

What structural change commonly follows resolution of an optic disc hemorrhage in glaucoma?

A rim notch or nerve fibre layer defect in the same sector Resolution often leaves a corresponding notch or thinning of the neuroretinal rim, or a retinal nerve fibre layer defect that may only appear months later.

A new epiretinal membrane over the disc

Enlargement of the physiological blind spot alone

What did the Ocular Hypertension Treatment Study show about eyes with an optic disc hemorrhage?

They had a substantially higher risk of developing open-angle glaucoma In that study, eyes found to have a disc hemorrhage carried a substantially greater risk of going on to develop primary open-angle glaucoma.

They had thicker central corneas than unaffected eyes

They responded poorly to topical prostaglandin therapy

They showed faster resolution of field defects

A treated glaucoma patient develops a new optic disc hemorrhage. What is the usual response?

Lower the pressure further and shorten the review interval A hemorrhage in an established glaucoma patient usually prompts additional pressure reduction and a shortened interval to the next visit.

Stop all topical therapy and observe the bleed

Arrange laser photocoagulation of the hemorrhage

Discharge the patient to routine community review

Which fundus findings point to retinal vein occlusion rather than an isolated glaucomatous disc hemorrhage?

Widespread retinal hemorrhages with venous dilation Retinal vein occlusion produces widespread retinal hemorrhages together with venous dilation, unlike the solitary splinter hemorrhage of glaucoma.

A crowded disc with buried refractile bodies

A single radial splinter at the rim margin

A pale swollen disc with no retinal hemorrhage

A patient on antiplatelet therapy is found to have an optic disc hemorrhage. What should they be told?

Continue the medicine unless a doctor advises otherwise Patients on anticoagulant or antiplatelet agents should not stop them without medical advice, because the systemic benefit far outweighs the risk to the disc.

Halve the dose until the hemorrhage has cleared

Switch immediately to an alternative agent

Stop the medicine until the next eye appointment

Optic Disc Hemorrhage: Glaucoma Risk and Workup

Optic disc hemorrhage is a small, flame-shaped or splinter hemorrhage at or near the optic disc margin, and in glaucoma it is also called a Drance hemorrhage.

It is a well-recognized risk factor for the development and progression of glaucoma.

Finding one should lead to a review of the patient’s pressure, disc, and visual field, and it should not be dismissed as an incidental finding.

What Is an Optic Disc Hemorrhage?

The hemorrhage lies in the superficial nerve fiber layer or at the border of the neuroretinal rim, and it is usually oriented radially along the nerve fibers.

It appears red and sharply demarcated, and it is frequently located in the inferotemporal or superotemporal region, which are the usual sites of early glaucomatous damage.

Drance and Begg described these hemorrhages in 1970 in patients with chronic open-angle glaucoma and suggested that they reflect an ischemic event at the disc.

The mechanism is not completely understood, but the proposals include mechanical damage from tissue stress at the lamina cribrosa and microvascular change.

Clinical Features

Most patients are asymptomatic, and the hemorrhage is found on the examination of the fundus.

The bleed usually resolves in weeks to a few months, and it often leaves a corresponding notch or thinning of the rim, or a defect in the retinal nerve fiber layer.

Recurrence is common, and repeated hemorrhages in the same eye indicate a higher risk of progression.

Hemorrhages occur more often in normal-tension glaucoma than in high-pressure glaucoma, and they are more frequent in women and in patients with migraine or vasospasm.

They can also be found in patients without known glaucoma, which is when they have the greatest value as a warning.

Test your knowledge 10 questions from this article

Importance of the Finding

The Ocular Hypertension Treatment Study found that eyes with a disc hemorrhage were at a substantially higher risk of developing primary open-angle glaucoma.

Other studies in established glaucoma show an association between hemorrhages and faster visual field progression.

For this reason, a disc hemorrhage should prompt a review of the treatment target in a patient who has glaucoma, and a careful follow-up in a patient who does not.

Differential Diagnosis

Posterior vitreous detachment: a hemorrhage at the disc margin, sometimes with a Weiss ring (see posterior vitreous detachment)
Diabetic or hypertensive retinopathy: other hemorrhages and vascular changes in the retina
Retinal vein occlusion: widespread hemorrhages, and venous dilation
Optic disc drusen: hemorrhages on or near a crowded disc (see optic disc drusen)
Anterior ischemic optic neuropathy: disc swelling with splinter hemorrhages
Anticoagulant or antiplatelet therapy: a contributing factor in some patients

Clinical eye photograph illustrating Optic Disc Hemorrhage Glaucoma

Evaluation and Management

Record the location and the size of the hemorrhage with a disc photograph, and compare it with the previous images.

Measure the pressure, check the angle, and perform a visual field and an OCT of the nerve fiber layer and the macula.

Review blood pressure, medication, and any systemic condition that could contribute, and consider the possibility of nocturnal hypotension in patients with normal-tension glaucoma.

In a patient with glaucoma, an additional reduction in pressure is usually considered when a hemorrhage is found, and the interval to the next visit is shortened (see normal-tension glaucoma).

In a patient without glaucoma, a hemorrhage is a reason for closer follow-up, and ocular hypertension should be evaluated with this finding in mind (see ocular hypertension).

Explain that the hemorrhage itself heals and does not harm vision, but that it indicates the need for vigilance.

Recording and Following Hemorrhages

A disc photograph is the best record, because a small hemorrhage is easily missed on a later visit if it has resolved.

Note the clock-hour location, the shape, and the relationship to the rim, and mark the corresponding area on the OCT printout.

Look for a nerve fiber layer defect in the same sector within the next months, because the defect often appears after the hemorrhage has gone.

A visual field test repeated at an interval can show whether the area has progressed.

Patient Counselling

Patients are often alarmed by the word hemorrhage.

Explain that the bleeding is tiny, that it clears by itself, and that it does not mean the eye is losing blood.

The point of the finding is that it tells the clinician that the optic nerve is under stress, and that treatment or monitoring may need to be adjusted.

Ask about migraine, cold hands and feet, low blood pressure, and sleep apnea, which are linked with normal-tension glaucoma.

Patients on anticoagulant or antiplatelet agents should not stop these medicines without medical advice, since the benefit of treatment is much larger than the risk to the disc.

References

Drance SM, Begg IS. Sector haemorrhage: a probable acute ischaemic disc change in chronic simple glaucoma. Can J Ophthalmol. 1970;5:137-141.
Budenz DL, Anderson DR, Feuer WJ, et al. Detection and prognostic significance of optic disc hemorrhages during the Ocular Hypertension Treatment Study. Ophthalmology. 2006;113:2137-2143.
Shields’ Textbook of Glaucoma. Allingham RR, Damji KF, Freedman S, et al, eds. 6th ed. Lippincott Williams and Wilkins; 2011.
American Academy of Ophthalmology. Basic and Clinical Science Course, Section 10: Glaucoma. AAO; current edition.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

What is the alternative name for a splinter hemorrhage at the optic disc margin in glaucoma?
A small flame-shaped or splinter hemorrhage at or near the disc margin in glaucoma is known as a Drance hemorrhage.
Where does a glaucomatous optic disc hemorrhage lie, and how is it oriented?
The hemorrhage sits in the superficial nerve fibre layer or at the border of the neuroretinal rim and runs radially along the course of the nerve fibres.
In which disc sectors are glaucomatous optic disc hemorrhages most often found?
These hemorrhages cluster inferotemporally and superotemporally, the regions where early glaucomatous damage typically occurs.
How long does a glaucomatous optic disc hemorrhage usually take to resolve?
The bleed clears over weeks to a few months, which is why a disc photograph is needed to document it before it disappears.
What structural change commonly follows resolution of an optic disc hemorrhage in glaucoma?
Resolution often leaves a corresponding notch or thinning of the neuroretinal rim, or a retinal nerve fibre layer defect that may only appear months later.
In which form of glaucoma are optic disc hemorrhages seen more frequently?
Disc hemorrhages occur more often in normal-tension glaucoma than in high-pressure glaucoma, and are more frequent in women and in patients with migraine or vasospasm.
What did the Ocular Hypertension Treatment Study show about eyes with an optic disc hemorrhage?
In that study, eyes found to have a disc hemorrhage carried a substantially greater risk of going on to develop primary open-angle glaucoma.
A treated glaucoma patient develops a new optic disc hemorrhage. What is the usual response?
A hemorrhage in an established glaucoma patient usually prompts additional pressure reduction and a shortened interval to the next visit.
Which fundus findings point to retinal vein occlusion rather than an isolated glaucomatous disc hemorrhage?
Retinal vein occlusion produces widespread retinal hemorrhages together with venous dilation, unlike the solitary splinter hemorrhage of glaucoma.
A patient on antiplatelet therapy is found to have an optic disc hemorrhage. What should they be told?
Patients on anticoagulant or antiplatelet agents should not stop them without medical advice, because the systemic benefit far outweighs the risk to the disc.