Ophthalmology Dx: Name This Disc Hemorrhage

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    This fundus image shows the left eye of a 21-year-old patient with sudden onset of a floater of 3 days duration.

A 21-year-old male reported seeing a floater in his left eye for the past 3 days following a particularly strenuous bike ride. The patient said the floater seems to change shape with his eye movements. The dilated indirect ophthalmoscopy exam was negative to the ora in both eyes. Screening visual fields at the visit were normal. His intraocular pressures measured 17 mm Hg in both eyes. His best-corrected visual acuity was 20/20 with refractions of -4.75 D in the right eye and -6.00 D in the left eye.  Which of the following was the most likely reason for these findings?

The vitreous body has several normal attachments to the retinal surface vessels and optic disc, and a strong attachment at the peripheral retina. Posterior vitreous detachment (PVD) is a normal part of the aging process. It results from syneresis, a...

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The vitreous body has several normal attachments to the retinal surface vessels and optic disc, and a strong attachment at the peripheral retina. Posterior vitreous detachment (PVD) is a normal part of the aging process. It results from syneresis, a process of contraction and liquificiation, of the vitreous.

In younger patients with myopia, an early stage partial vitreous detachment can occur after vigorous head movement.1 The up-and-down head movements from the patient’s long bike riding may have caused the early part of a PVD, when the vitreous pulls on its attachment to the disc margin causing leakage of blood from the disc margin vessels. Posterior vitreous detachment can be segmented into 4 stages. Stage 1 is a perifoveal PVD with residual vitreofoveal attachment. Stage 2 is a macular PVD with no vitreofoveal adhesion. Stage 3 is a near-complete PVD, with only vitreopapillary adhesion remaining. Stage 4 is a complete PVD.2

In this case, the area of blood from the disc margin vessels looks similar to a Drance hemorrhage, which is an important indicator of glaucoma progression. Younger patients may have glaucoma, but the sign that glaucoma is not this patient’s problem is the nature of the optic nerve head disc. Glaucoma causes vertical cupping of the optic disc. This patient has normal, horizontal cupping and good rim tissue.

Cases such as this one require the clinician to first rule out a full retinal detachment or any breaks or signs of papilledema. This patient was managed with follow-up in 1 week and told to call at any time if visual changes were noticed and seen again in 4 to 6 weeks. 

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

References

1. Chuo J, Lee T, Hollands H, et al. Risk factors for posterior vitreous detachment: a case-control study. Am J Ophthalmol. 2006;142(6):P931-P937.E1. doi: 10.1016/j.ajo.2006.08.0022. Hwang E, Kraker J, Koller E. Progression of partial posterior vitreous detachment over time. ARVO Meeting Abstract. Invest Ophthalmol Vis Sci. 2020;61(6):4821.

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