Ophthalmology Dx: A Workout That Didn’t Work Out

Slideshow

  • Figure 1. A 24-year-old patient's right eye fundus photo revealed a flame hemorrhage at the inferior disc margin. This hemorrhage resolved by his 3-week follow-up appointment.

  • Figure 2. Three weeks after initial presentation, this new small segmented hemorrhage was found in the same patient's left eye.

A 24-year-old male presented with a complaint of “seeing spots in his right eye.” This was first noticed after strenuous exercise the previous day. His vision was 20/20 in each eye, with a bilateral 6.00 D myopic correction. Pupillary testing was normal. His pressures were 18 mm Hg OU and direct ophthalmoscopy revealed a flame hemorrhage at the inferior disc margin in the right eye (Figure 1) with cup-to-disc ratio of 0.5 OD and 0.6 OS. A dilated indirect exam was normal. He was scheduled for a visual fields exam in 3 weeks and told to immediately report any visual changes. At the 3-week visit, the flame hemorrhage in the right eye had resolved, but a new small segmented hemorrhage was found in the left eye (Figure 2) in the inferior disk rim and in the adjacent prelaminar optic nerve layer and nerve fiber layer. The exam revealed normal visual fields in his right eye, but a small superior defect in the left. The location was predictable from the location of the blood in the nerve fiber layer shown on the fundus photo. Repeat fields were consistent with the original findings. Diurnal pressure plotting at different times of the day did not result in any pressures greater than 20 mm Hg in either eye. Gonioscopy was normal, with no pigment in the angles.

Disc hemorrhages (DH) in glaucoma tend to be small with feathered edges and extend from within the RNFL of the optic disc into the peripapillary region. They are often associated with and adjacent to structural changes in the optic disc...

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Disc hemorrhages (DH) in glaucoma tend to be small with feathered edges and extend from within the RNFL of the optic disc into the peripapillary region. They are often associated with and adjacent to structural changes in the optic disc rim.1 The common location of the DH is at the temporal aspect of the disc. On careful examination of this patient, the DH in the left eye seems to be rotated clockwise and the DH is at 6:30 position. After a slight correction adjusting for the rotation of the disc, the hemorrhage was determined to be in the inferior temporal location.

Several studies, including the Baltimore Eye Study and the Beaver Dam Eye Study, report that many patients with primary open-angle glaucoma have pressures lower than 22 mm Hg upon initial screenings. This patient’s clinical findings are most consistent with low tension glaucoma in the left eye.

Disc hemorrhages are common in patients with low tension glaucoma and found in 20% of cases.2 The location of the patient’s hemorrhage is most commonly at the inferior disc margin in patients with glaucoma. It resolved after four weeks, but recurrences are common.3 The field defect location is frequently located superiorly during the early stage of glaucoma. In this case, it is consistent with the location of the hemorrhage in the nerve fiber layer. A patient’s hemorrhages are located in the prelaminar area of the optic disc and adjacent superficial nerve fiber area and may not be exactly flame-shaped.4

The diagnosis of low tension glaucoma was confirmed after a complete medical workup, and consultations with 2 glaucoma specialists. The patient was treated and followed by one of the glaucoma specialists. 

The DH in the right eye is in the temporal location, but large, without feathered edges and it covers the vessels. The DH does not have a corresponding field defect. In addition, the patient’s initial complaint of suddenly seeing spots would make it most likely to be a vitreous traction event rather than a disc rim deterioration event. Glaucoma disc hemorrhage patients do not have symptoms of suddenly seeing spots, because these hemorrhages are located within the tissue itself and not on the retinal surface.4

The vigorous head movement during strenuous exercise caused the vitreous attached to the vessels at the disc margin caused those vessels to leak blood at the disc margin (flame hemorrhage) and also in the posterior vitreous body, closest to the retina (patient seeing spots).

References

1. Gorman TF, Doraiaj S. Disc hemorrhages in eyes with glaucoma. EyeNet Magazine. Published online May 2014. 

2. Johnson MW. Perifoveal vitreous detachment and its macula complications. Am J Ophthalmol. 2006;141:792-793. doi:10.1016/j.ajo.2006.02.012. 

3. Kitazawa Y,  Shirato S, Yamamoto T.  Optic disc hemorrhage in low-tension glaucoma. Ophthalmol. 1986;93(6):853-857. doi:10.1016/s0161-6420(86)33658-3. 

4.  Drance SM. Disc hemorrhages in the glaucomas. Surv Ophthalmol. 1989;33(5):331-337. doi:10.1016/0039-6257(89)90010-6.

Matthew Garston, OD, is an adjunct professor at the New England College of Optometry and was a senior staff optometrist in the medical department at MIT for 43 years.

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