Optic disc hemorrhages in glaucoma and common clinical

features
Zeynep Kayaarasi Ozturker, MD,*,† Kristen Munro, BHSc,*,‡ Neeru Gupta, MD, PhD, MBA*,†,‡,§,ǁ
ABSTRACT ● RÉSUMÉ
Objective: To analyze optic nerve head stereophotographs for the presence of optic disc hemorrhages, and to describe bleeding
patterns and patient characteristics.
Design: Retrospective, cross-sectional study.
Participants: 1113 optic nerve stereophotograph pairs of 562 consecutive patients.
Methods: Stereophotographs were systematically reviewed for the presence of a disc hemorrhage with careful documentation of
optic nerve head features. All charts of patients with hemorrhage were subsequently studied for demographic information and
clinical data.
Results: Disc hemorrhages were observed in 7.1% of patients with optic disc photography. Most patients had open-angle glaucoma
(57.5%) with focal ischemic phenotype of the optic disc (66.7%). The mean vertical and horizontal cup–disc ratios were 0.82 ⫾
0.14 and 0.76 ⫾ 0.14, respectively. The β-zone peripapillary atrophy was observed in 48.9% of patients. The most common
location was the inferotemporal region of the disc (60.8%), and most were flame or splinter shaped (70.6%). Disc hemorrhages
were found either superficial to or within the retinal nerve fibre layer (72.5%), and in association with a notch (64.4%). The average
intraocular pressure was 17.3 ⫾ 4.9 mm Hg, and most hemorrhages were associated with early visual field defects (42.5%).
Conclusions: Optic disc hemorrhages in patients with glaucoma were most frequently observed inferiorly in association with a
notch. Most eyes with a disc hemorrhage had an intraocular pressure within normal range and had either early or no visual field
loss. These findings highlight the importance of careful examination of the optic nerve head to look for the presence of a disc
hemorrhage as an important biomarker of glaucoma damage.

Objet : Analyser des stéréophotographies de la tête du nerf optique à la recherche d’hémorragies du disque optique, et décrire les
types d’hémorragies de même que les caractéristiques des patients.
Nature : Analyse transversale rétrospective
Participants : 1113 paires de stéréophotographies du nerf optique provenant de 562 patients consécutifs.
Méthodes : Les stéréophotographies ont été examinées systématiquement à la recherche d’une hémorragie discale en
documentant avec soin les caractéristiques de la tête du nerf optique. On a ensuite passé en revue les dossiers des patients
ayant subi une hémorragie afin d’en extraire les données démographiques et cliniques.
Résultats : Quelque 7,1 % des patients photographiés ont présenté une hémorragie du disque optique. La plupart des patients
avaient un glaucome à angle ouvert (57,5 %) dont le disque optique était de phénotype « ischémie focale » (66,7 %). Les rapports
cupule/disque verticaux et horizontaux moyens étaient de 0,82 ± 0,14 et de 0,76 ± 0,14, respectivement. Une zone d’atrophie
péripapillaire β a été observée chez 48,9 % des patients. La localisation la plus fréquente était le territoire inférotemporal du
disque (60,8 %), et dans la plupart des cas, il s’agissait d’hémorragies en flammèche de Drance (70,6 %). Les hémorragies
discales se trouvaient en superficie de la couche de fibres nerveuses de la rétine ou à l’intérieur de cette dernière (72,5 %), et
s’accompagnaient d’une encoche (64,4 %). La pression intraoculaire (PIO) moyenne se chiffrait à 17,3 ± 4,9 mm Hg, et la plupart
des hémorragies étaient associées à des lacunes précoces du champ visuel (42,5 %).
Conclusions : Les hémorragies du disque optique en présence de glaucome touchaient le plus souvent le territoire inférieur et
s’accompagnaient d’une encoche. La PIO de la plupart des yeux ayant subi une hémorragie discale se situait à l’intérieur des
valeurs normales, et les lacunes du champ visuel étaient soit précoces, soit inexistantes. Ces observations soulignent
l’importance de rechercher attentivement la présence d’une hémorragie discale de la tête du nerf optique, puisqu’il s’agit d’un
biomarqueur important dans le traitement du glaucome.

Glaucoma is an irreversible optic neuropathy associated
with progressive morphological changes of the optic nerve
head and vision loss. Optic disc hemorrhage is an
important identifiable risk factor for disease progres-
sion.1–4 The finding of a disc hemorrhage may indicate
the presence of glaucomatous damage even if the visual
field (VF) is unremarkable.5–10 Hence, it is highly specific
for the possibility of glaucoma in the absence of diabetic
and hypertensive bleedings, ischemic optic neuropathies,
and other vascular diseases of the retina.11 Various
hypotheses, such as hemodynamic and mechanical
disturbance, have been proposed; however, the exact
pathogenesis is not yet fully understood.12–20 At present,
optic disc imaging technologies are unable to detect optic
disc hemorrhages, and direct evaluation and photography
of optic disc remain the gold standard for their
detection.21
The importance of disc hemorrhage as an important sign of
glaucomatous damage was brought to light by Drance and
Begg in 1970 in Vancouver, Canada.22 Drance and colleagues
also found that a disc hemorrhage was a risk factor for
glaucoma progression.23 Characteristics of disc hemorrhages in

& 2017 The Authors. Published by Elsevier Inc. on behalf

of Canadian Ophthalmological Society. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2017.04.011
ISSN 0008-4182/17

CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017 583

Optic disc hemorrhages in glaucoma—Ozturker et al.

relation to glaucoma have been published in the United loss, β-zone peripapillary atrophy, acquired pit of the
States,24–27 Australia,28,29 Germany,30 England,31 optic nerve, and focal or diffuse RNFL loss were recorded
8,32,33 9,34,35 36,37
Finland, Sweden, Japan, China, Korea,39,40
38
from the stereophotographs. Optic discs were classified
41,42 43,44
Taiwan, Singapore, and India.45 Some studies according to focal ischemic, senile sclerotic, concentric
have characterized optic disc hemorrhage appearance, and enlargement of the optic cup, and myopic glaucomatous
location.25,27,30–32,34,37,39,41,42 Others have evaluated disc phenotypes.49 Notches were classified as being
optic disc hemorrhages in relation to the glaucoma within the neuroretinal rim or extending to the disc
type, 9,27,28,30,36,42,43,45 systemic comorbidities, and medi- margin.48
cations.25,27,29,35,37,39,40,44,46,47 Several studies have specif- After complete assessment and characterization of all
ically evaluated rim thinning, retinal nerve fibre layer disc photographs, charts were reviewed for the following
(RNFL) loss, and peripapillary atrophy.9,25–28,30,32,38,39,43–45,48 clinical data: age at first disc hemorrhage, sex, race, type of
Various studies have also looked at intraocular pressure glaucoma, family history of glaucoma, smoking status,
(IOP), and VF defects.9,10,25,28–32,34,37–44 IOP, and use of antiglaucoma medications. VFs within
No single study has evaluated all of these clinical 6 months were recorded for 40 eyes out of 45 eyes with a
features together. In this comprehensive study, we char- hemorrhage. VF defects and mean deviation (MD) results
acterize optic disc hemorrhages in relation to glaucoma analyzed by Humphrey perimeter 24–2 were evaluated.
type, optic disc phenotype, IOP, VF loss, and morpho- Glaucoma severity was categorized according to the
logical features and patterns of microbleeds. Understand- Hodapp–Anderson–Parrish grading scale as follows: stage
ing clinical characteristics in relation to hemorrhages of the 1 (early defect, MD Z
6.00 dB), stage 2 (moderate
optic nerve head may provide added insights into glau- defect, MD of
6.01 to
12.00 dB), and stage 3
comatous damage. (advanced defect, MD o
12.00).50 The presence of
systemic comorbidities such as hypertension, diabetes,
ischemic heart disease, asthma, thyroid disease, migraine,
METHODS and Raynaud phenomenon and medications such as
Institutional Research Ethics Board approval (REB 16- aspirin, beta-blockers, steroids, and anticoagulants, was
228C) was obtained from St. Michael’s Hospital, Uni- also investigated.
versity of Toronto, Toronto, Canada. We systematically
evaluated 1113 consecutive photographs representing eyes Table 1—Demographic data and clinical
of 562 patients at the Glaucoma Unit, St. Michael’s characteristics of patients with optic disc
Hospital (N.G. and Z.K.O.). Of these patients, 11 had hemorrhage
monocular status. A disc hemorrhage was defined as a Variable Patients (n ¼ 40)
hemorrhage within one disc diameter of the optic nerve. Age (years)
Mean ⫾ SD 64.1 ⫾ 14.3
Exclusion criteria included subjects with hemorrhages in Range 35–90
association with diabetic and hypertensive retinopathy, Sex
ischemic optic neuropathies, and other vascular diseases of Female 57.5% (23)
Male 42.5% (17)
the retina. Three eyes of 3 monocular patients were Race
excluded because of low stereoscopic image quality, and Caucasian 80% (32)
Asian 15% (6)
1 patient was excluded because of interferon-associated Black 5% (2)
retinopathy. Systemic diseases
The location of the disc hemorrhages was documented Hypertension 35% (14)
Ischemic heart disease 15% (6)
according to their clock-hour sectors. Superior, inferior, Asthma 12.5% (5)
temporal, and nasal regions were also recorded. For both Diabetes 5% (2)
Thyroid disease 5% (2)
eyes, superior and inferior regions corresponded to 11 to Migraine 5% (2)
1 o’clock and 5 to 7 o’clock sectors, respectively. Nasal Coagulation disorders 2.5% (1)
and temporal regions corresponded to 2 to 4 o’clock and Raynaud phenomenon 2.5% (1)
Systemic medications
8 to 10 o’clock sectors in the right eye and 8 to 10 o’clock Aspirin 35% (14)
and 2 to 4 o’clock sectors in the left eye, respectively. The Beta-blockers 12.5% (5)
appearances of hemorrhages were classified as flame or Steroids
Anticoagulants
5% (2)
2.5% (1)
splinter, dot or blot, and diffuse type. A diffuse hemor- Glaucoma diagnoses
rhage was defined as a bleed at least half the size of a clock- Open-angle 57.5% (23)
Normal tension 37.5% (15)
hour sector. The depth of the hemorrhages was also Angle-closure 5% (2)
grouped according to 3 different levels: superficial to or Family history of glaucoma
Negative 65% (26)
within the RNFL, prelaminar region, and laminar
Positive 35% (14)
region.32 Laterality of the hemorrhages was also recorded. Smoking status
Optic nerve head parameters such as disc appearance, Active 5% (2)
History 20% (8)
cup–disc ratio, neuroretinal rim notch, neuroretinal rim

584 CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017

 Optic disc hemorrhages in glaucoma—Ozturker et al.

A B

↓
→

C D

Fig. 1 — Optic disc phenotypes with optic disc hemorrhages included focal ischemic (A), senile sclerotic (B), myopic
glaucomatous (C), and concentric enlargement (D) types.

Statistical Analysis Table 2—Morphologic characteristics of eyes with optic disc

hemorrhage
The data were processed descriptively and statistically in
Microsoft Excel 2010 by the significance of p o 0.05. Variable Eyes (n ¼ 45)
One-way analysis of variance was used to compare IOP for Optic disc appearance
Focal ischemic 66.7% (30)
eyes with optic disc hemorrhages at different optic disc Senile sclerotic 15.6% (7)
sectors. Myopic glaucomatous 13.3% (6)
Concentric enlargement of the optic cup 4.4% (2)
Cup–disc ratio
Vertical 0.82 ⫾ 0.14
RESULTS Horizontal 0.76 ⫾ 0.14
Rim loss*
Demographics and comorbidities Inferior 60% (27)
The study included 1108 disc photographs of 558 Superior 51.1% (23)
Temporal 26.7% (12)
patients. Of these, 40 patients (7.1%) had an optic disc Nasal 2.2% (1)
hemorrhage. The mean age was 64.1 ⫾ 14.3 years (range, Notch
35 to 90 years). Most patients were Caucasian (80%) and Normal tension glaucoma 76.5% (13/17)
Open-angle glaucoma 73.1% (19/26)
female (57.5%). Twenty-three (57.5%) patients with a β-zone peripapillary atrophy 48.9% (22)
disc hemorrhage had open-angle glaucoma, 15 (37.5%) Acquired pit of the optic nerve 22.2% (10)
Nerve fibre layer loss
had normal tension glaucoma, and 2 (5%) had angle- Focal
closure glaucoma (Table 1). A review of systemic diseases Inferior 11.1% (5)
showed that 14 patients (35%) had hypertension, 6 (15%) Superior 2.2% (1)
Diffuse 2.2% (1)
had ischemic heart disease, 5 (12.5%) had asthma, 2 (5%)
*Some eyes had rim loss in more than one quadrant.
had diabetes, 2 (5%) had thyroid disease, 2 (5%) had

CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017 585

Optic disc hemorrhages in glaucoma—Ozturker et al.

Fig. 2 — Right and left eyes of a patient show a disc hemorrhage at 7 o’clock in the right eye (A), and two hemorrhages at the 5
and 6 o’clock positions in the left eye (B) (arrows). Right and left eyes of a patient show no hemorrhage in the right eye (C), and
in the left eye, two hemorrhages at the 12 and 6 o’clock positions (D) (arrows).

migraine, 1 (2.5%) had factor V clotting disorder, and 1
(2.5%) had Raynaud phenomenon. A review of systemic
medications showed that 14 patients (35%) were using
aspirin, 5 (12.5%) were using systemic beta-blockers, 2
(5%) were using steroids, and 1 patient (2.5%) was on
anticoagulant therapy. Among those with disc hemor-
rhages, 35% had a family history of glaucoma and 25%
had a lifetime history of smoking (Table 1).
Optic nerve morphology with disc hemorrhage
Fifty-one optic disc hemorrhages were detected in 45
eyes of 40 patients. Hemorrhages were most often seen in
the focal ischemic glaucomatous optic nerves (66.7%)
(Fig. 1A). A hemorrhage was less often seen in senile
sclerotic (15.6%) (Fig. 1B), myopic glaucomatous
(13.3%) (Fig. 1C), and concentric enlargement optic
nerve phenotypes (4.4%) (Fig. 1D).
The mean vertical and horizontal cup–disc ratios were
0.82 ⫾ 0.14 and 0.76 ⫾ 0.14, respectively. Disc
hemorrhages were most associated with inferior rim loss
(60%) followed by superior (51.1%), temporal (26.7%),
and nasal (2.2%). The β-zone peripapillary atrophy was
noted in 48.9% of eyes, and an acquired pit of the optic
nerve was noted in 22.2% of eyes. Focal RNFL loss was
observed in 13.3% of eyes, and in all cases, the site of focal
RNFL loss corresponded to the site of the disc hemor-
rhage. Most RNFL loss was located (11.1%) inferiorly.
A rim notch was seen in 73.3% of the eyes with a disc
hemorrhage with similar frequencies in normal tension
glaucoma (76.5%) and open-angle glaucoma (73.1%).
Most of the notches (77.7%) were within the neuroretinal
rim. Morphologic characteristics of 45 eyes with at least
one optic disc hemorrhage are summarized in Table 2.
Disc hemorrhage appearance and location
Hemorrhages were detected in 1 eye in 35 patients
(87.5%) (Fig. 2A, B), and in both eyes of 5 patients
(12.5%) (Fig. 2C, D). There was no difference in the

586 CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017

 Optic disc hemorrhages in glaucoma—Ozturker et al.

A B

C D

Fig. 3 — Optic disc hemorrhages showed flame or splinter (A), dot (B), blot (C), and diffuse bleeding (D) patterns in nerve fiber
layer (A), prelaminar (B,C) and laminar (D) regions.

number of detected hemorrhages between the right and

Table 3—Depth of optic disc hemorrhages
the left eye. In 5 patients, 2 hemorrhages were noted in
Percent of Optic Disc 1 eye as in Figure 2B and 2D.
Location Hemorrhages (n)
The majority of optic disc hemorrhages were flame or
Superficial to or within the nerve fibre 72.5% (37)
layer splinter shaped (70.6%) and superficial to or within the
Prelaminar region 17.7% (9) RNFL (72.5%) (Fig. 3A). Dot- or blot-shaped hemorrhages
Laminar region 9.8% (5)
(23.5%) (Fig. 3B, C) and diffuse bleeds (5.9%) (Fig. 3D)

Right Eye 12 Left Eye 12

5,9%
3,9% 7,8%
5,9%

2,0% 3,9% 2,0%

9 3 9 3
3,9% 2,0%

2,0%

17.6% 23,5%
9,8% 9,8%

6 6

Fig. 4 — Frequency distribution of optic disc hemorrhages at clock-hours of the optic nerve head showed that most were
inferiorly located, at 7 o’clock and 5 o’clock in the right and left eyes, respectively.

CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017 587

Optic disc hemorrhages in glaucoma—Ozturker et al.

Table 4—Morphologic characteristics of optic disc hemor- Table 6—Glaucoma medications

rhages in relation to the notches and optic disc hemorrhages

Variable Disc Hemorrhages (n ¼ 29) Eyes

Location Variable (n ¼ 45)
Inferior 60% (17) No glaucoma medication 46.7% (21)
Superior 40% (12) Glaucoma medication* 53.3% (24)
Nasal — Beta-blocker 35.6% (16)
Temporal — Prostaglandin analog 26.7% (12)
Shape Adrenergic agonist 15.6% (7)
Splinter or flame 75.8% (22) Carbonic anhydrase inhibitor 13.3% (6)
Dot or blot 17.2% (5) Cholinergic agonist 6.7% (3)
Diffuse 6.8% (2)
*Some patients were using fixed combination anti-
Depth
glaucoma medications.
Superficial to or within the nerve fibre layer 79.3% (23)
Prelaminar region 26% (6)
Laminar region —

agonists (15.6%), carbonic anhydrase inhibitors (13.3%),

and cholinergic agonists (6.7%) (Table 6).
were noted less frequently and sometimes observed in
deeper prelaminar and laminar regions of the optic nerve
head (Fig. 3B–D). The various depths of hemorrhages are Visual field loss and disc hemorrhage
shown in Table 3. Hemorrhages were most commonly The average VF loss in eyes with a disc hemorrhage was
located in the inferotemporal region (60.8%), with the
6.6 ⫾ 6.6 dB. Eight eyes with hemorrhage showed no
hemorrhages most commonly located at 7 o’clock in right VF abnormality. Among 32 eyes (80%) with VF loss,
eyes (17.6%) and 5 o’clock in left eyes (23.5%) (Fig. 4). 42.5% had early stage, 20% had moderate stage, and
Disc hemorrhage was located at the same or adjacent 17.5% had advanced stage glaucoma based on the
clock-hour as the notch in 29 (64.4%) eyes. Hemorrhages Hodapp–Anderson–Parrish classification (Table 7)
accompanying a notch were mostly located in the inferior (Fig. 5). Sixty-eight percent of the hemorrhages correlated
(60%) or superior (40%) quadrants of the disc, and were with the VF defect location.
not observed in nasal and temporal quadrants. Of these The location of optic disc hemorrhages according to the
hemorrhages, 75.8% had splinter or flame, 17.2% had dot degree of VF loss is shown in Figure 6. In eyes with no VF
or blot, and 6.8% had diffuse shape. The majority of these loss, most hemorrhages were located in the inferotemporal
hemorrhages were superficial to or within the RNFL region (33.4%), followed by superior (22.2%) and inferior
(79.3%), and fewer were in the prelaminar region (22.2%) regions. In cases of early VF loss, hemorrhages
(20.6%) (Table 4). were located mostly in the inferotemporal region (53.0%),
Table 7—Visual field results for
eyes with optic disc hemorrhage
Intraocular pressure and optic disc hemorrhage Eyes
In eyes with a hemorrhage, the average IOP was 17.3 ⫾ Variable (n ¼ 40)
4.9 mm Hg. There was no difference in mean IOP Visual field defect 80% (32)
Glaucoma stage*
between the eyes with a hemorrhage in superior, inferior, Early (Z
6 dB) 42.5% (17)
temporal, and nasal sectors (p ¼ 0.072) (Table 5). Moderate (
6.01 to
12 dB) 20% (8)
Advanced (o
12.01 dB) 17.5% (7)
Fifty-three percent of eyes were on antiglaucoma medi-
cations at the time of a detected hemorrhage with an *Glaucoma stage according to the Hodapp–Ander-
son–Parrish scale. Mean deviation in decibels (dB).
average of 1.9 ⫾ 0.8 m (range 1–4 m). The eyes were on
the following antiglaucoma medications: beta-blockers
(35.6%), prostaglandin analogues (26.7%), adrenergic
Visual Field Loss
17.5% 20%
Table 5—Mean intraocular pressure in eyes with optic disc
hemorrhages None
N (eyes) Mean IOP (mm Hg) 20% Early
Total 45 17.3 ⫾ 4.9
Optic disc sector* 42.5% Moderate
Superior 10 19.0 ⫾ 6.4
Inferior 28 16.0 ⫾ 6.4
Advanced
Temporal 3 13.6 ⫾ 4.7
Nasal 2 20.0 ⫾ 4.2
Fig. 5 — Frequency distribution of visual field loss in eyes with
IOP, intraocular pressure.
a disc hemorrhage shows that most had early visual field loss
*Two eyes were excluded due to hemorrhages in more than one sector.
(Hodapp-Anderson-Parrish scale).

588 CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017


Normal VF Early
S S
22.2% 5.9%
11.1% 17.6%
T 11.1% N T
33.4% 53.0%
22.2% 17.6%
I I
Fig. 6 — Frequency distribution of optic disc hemorrhages at various quadrant locations according to the degree of visual field
loss are shown (Hodapp-Anderson-Parrish scale).
(S: Superior, I: Inferior, T: Temporal, N: Nasal)
followed by the inferior (17.6%) and superotemporal
regions (17.6%). With moderate VF loss, 62.5% of
hemorrhages were located in the inferotemporal region
and 25% were in the superior region. In cases of advanced
VF loss, hemorrhages were mostly in the superonasal
region (28.5%), followed by temporal (14.3%), super-
otemporal (14.3%), nasal (14.3%), superonasal (14.3%),
and inferior (14.3%) regions.
DISCUSSION
We detected a disc hemorrhage in 7.1% of the patients
evaluated in a consecutive series of glaucomatous optic
nerve photographs. This is similar to findings in a 1972
Canadian study by Kottler and Drance (6.8%).51 It has
been reported as high as 13.8% in Australia,29 and as low
as 0.8% in the United States.27 Disc hemorrhages were
found most commonly in patients with open-angle
glaucoma (57.5%), followed by normal tension glaucoma
(37.5%) and angle-closure glaucoma (5%). Studies from
Asia36,52 and Europe30,31,53 observed disc hemorrhages
more frequently in normal tension glaucoma. Fewer
patients had angle-closure glaucoma, consistent with
previous studies.43,54 One study from Taiwan suggested
that they are not so rare.41 More women had disc
hemorrhage, and this is consistent with studies from the
United States,26,27,47 Finland,32 and Denmark34; how-
ever, sex difference was not detected in other studies,22,52
and the influence of sex on the development of disc
hemorrhage remains unclear.
A review of systemic comorbidities revealed that
one-third of our patients with disc hemorrhage had
hypertension. Hypertension in association with a disc
hemorrhage has been reported in studies from
Canada,23,51 Korea,17 and Australia28,29; however, other
studies did not find such an association.25,35,47,55 Diabetes
and migraine were detected in only 5% of our patients,
although a positive association has been previously
reported.24,25,29,35,47,51,55,56 Whether diabetes influences
Optic disc hemorrhages in glaucoma—Ozturker et al.
Moderate Advanced
S S
25%
28.5%
14.3%
N T N T 14.3% 14.3% N
14.3%
5.9% 62.5%
12.5% 14.3%
I I
the occurrence of hemorrhage remains controversial. An
association between migraine and disc hemorrhage has
been reported in normal tension glaucoma46; however,
this association has not been reported in open-angle
glaucoma.29 Aspirin use was present in one-third of our
patients which is consistent with the studies suggesting
that platelet aggregation inhibition may be implicated.17,47
Systemic beta-blocker was used in 12.5% of our patients,
and a relationship to disc hemorrhage was previously
reported by Furlanetto et al. in a group of normal tension
glaucoma patients.46 Family history of glaucoma was
found in 35% of our patients and a lifetime history of
smoking in 25% of patients. Both family history and
smoking were associated with disc hemorrhage in the
Ocular Hypertension Treatment Study3; however, no
association was found in glaucoma patients in a
population-based study.29
Most hemorrhages were unilateral (88%), similar to
other studies.23,24,32 Five of our patients had 2 optic nerve
hemorrhages in a single eye, and this pattern has also been
described by Airaksinen et al.32 Various optic disc
phenotypes have been described in glaucoma.49,57 We
observed disc hemorrhages mostly in the focal ischemic
phenotype (66.7%), consistent with a previous Canadian
study,49 although senile sclerotic phenotype was more
commonly associated in a smaller U.S. study.58
An inferior hemorrhage in association with a rim notch
was commonly seen in our study. Notches adjacent to
hemorrhages were mostly within the neuroretinal rim, and
fewer extended to the disc margin. These findings agree
with other studies that suggest that bleeding is a result of
ongoing structural loss.15,59–61 Most studies indicate that
neuroretinal rim is necessary for the development of a disc
hemorrhage.30,62,63 We found that localized nerve fibre
layer loss corresponded with the hemorrhage. Studies
using red-free fundus photographs from Germany30
(35%) and Finland8 (46%) showed more frequent RNFL
defects in association with disc hemorrhages, and when
evaluated by scanning laser ophthalmoscopy, approached
CAN J OPHTHALMOL — VOL. 52, NO. 6, DECEMBER 2017 589
Optic disc hemorrhages in glaucoma—Ozturker et al.
80%.64 Nearly half of the eyes had β-zone peripapillary
atrophy in association with hemorrhages, consistent with
other studies, and blood flow insufficiency around the
optic disc has been implicated.26,65–68
The mean IOP of patients with disc hemorrhage was in
the midteens, and IOP level did not appear to correlate
with any particular disc hemorrhage location. Other
studies suggest that disc hemorrhage is not dependent
on IOP, with considerable evidence of progressive glau-
coma despite good control of IOP in eyes with a
hemorrhage.4,25,29,36,51,52,69,70
We found that 80% of eyes with a disc hemorrhage had
a VF abnormality, most commonly affecting the superior
field. Most hemorrhages were in association with early VF
loss. However, in cases of more advanced field loss,
superior, temporal, and nasal locations were more fre-
quently affected, and this pattern has been previously
observed.30,34
Optic disc assessment is a valuable tool in the diagnosis
and follow-up of patients with glaucoma. Detection of a
disc hemorrhage plays an essential role in the prognosis of
the disease as it is a harbinger of progressive functional
vision loss in glaucoma.23,53,61,71,72 Unfortunately, com-
monly used digital imaging devices such as optical
coherence tomography, scanning laser ophthalmoscopy,
and scanning laser polarimetry are not capable of detecting
disc hemorrhages. This highlights the importance of a
clinical examination. Optic disc photography provides
both qualitative and quantitative information of the optic
nerve head in glaucoma, and can also detect subtle
hemorrhages. Clinical examination of the optic nerve head
remains a cornerstone of glaucoma eye care. The mech-
anisms underlying disc hemorrhages and progressive
optic nerve damage remain unclear. Further investigation
to understand microbleeds in glaucoma may help us
to manage the disease better and prevent avoidable
vision loss.
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Footnotes and Disclosure:
The authors have no proprietary or commercial interest in any
materials discussed in this article.
Support from Thor and Nicky Eaton Fund, Keenan Research
Summer Program, and Canada Summer Jobs (K.M.).
From the *Glaucoma Unit, University of Toronto, Toronto,
Ont.; †Ophthalmology & Vision Sciences, University of Tor-
onto, Toronto, Ont.; ‡Keenan Research Center, Li Ka Shing
Knowledge Institute, St. Michael’s Hospital, Toronto, Ont.;
§Laboratory Medicine & Pathobiology, University of Toronto,
Toronto, Ont.; ǁDalla Lana School of Public Health, University
of Toronto, Toronto, Ont.
Originally received Jan. 18, 2017. Final revision Apr. 9, 2017.
Accepted Apr. 12, 2017.
Correspondence to Neeru Gupta, MD, St. Michael’s Hospital,
30 Bond Street, Cardinal Carter Wing, 8-072, Toronto, Ont.
M5B 1W8; guptan@smh.ca
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