Disc Hemorrhage May Indicate Faster Structural Deterioration in Glaucoma

Repeated disc hemorrhage (DH) in glaucoma may indicate vulnerability to faster structural deterioration at the DH site, according to a study published in Ophthalmology Glaucoma.

In this study planned as the first analysis of a 3-year prospective cohort study, researchers investigated the spatial and temporal relationship between DH and structural progression in patients aged ≥20 years with primary open-angle glaucoma (N=150). Structural progression was defined by the widening or emergence of retinal nerve fiber layer defects (RNFLDs), rim thinning, or enlarged cupping. The researchers analyzed fundus photographs centered on the optic disc taken at baseline and every 3 months for 3 years to detect DH and structural progression independently by flicker chronoscopy.

At baseline, 32 of 195 eyes (16.4%) had DH. During the study period, the researchers found 227 incidences of DH at 85 sites in 65 eyes (33.3%) from 57 patients (49.6%). DH was more frequently observed at the 7 o’clock position (38.3% of all DH, 29.4% of total DH sites, and 3.48 times/DH site [P <.0001]). According to their relationship with RNFLDs, DH sites were classified into 3 types: DH on the nasal RNFLD border (14 sites, 16.5%), DH on the temporal RNFLD border (54 sites, 63.5%), and DH unrelated to RNFLDs (14 sites, 16.5%).

There were 84 events of structural progression at 63 disc locations in 52 eyes (26.7%) in 41 patients (36.9%); most progressions were RNFLDs widening toward the temporal side (43 of 63 sites, 68.3%). Progression occurred similarly in both hemidiscs (31 superior and 32 inferior sites). Of 41 progression sites in eyes with DH, 28 had both DH and progression. At sites where progression occurred following DH, time from DH onset to progression was significantly longer in sites with baseline DH compared with sites with follow-up DH only (P =.017). Eyes with DH were found to be at significantly higher risk for progression than those without DH (hazard ratio 3.72±1.13; P <.0001).

Limitations of this study include similar characteristics among the patients; the results may therefore not apply to patients of other ethnicities, those with higher intraocular pressure, and those who underwent different treatment. Certain potentially confounding factors for progression that could influence the relationship between DH and progression were not part of the analysis. Systemic diseases and their medications may modify the occurrence of DH. The rate of change may be underestimated, as the researchers used nonstereoscopic fundus photos to detect structural progression and DH. Some DH events could have been missed because fundus photos were taken every 3 months.

“We should pay special attention to repeated DH occurrence at the same disc location, which may indicate faster structural deterioration there,” the researchers concluded. “From a clinical perspective, frequently taking fundus photos and comparing pairs of photos using flicker chronoscopy is effective for detecting DH without omission in patients with [primary open-angle glaucoma], although the viewing system requires extra effort and costs for preparation.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Higashide T, Ohkubo S, Udagawa S, et al; for SVF prospector study group. Spatial and temporal relationship between structural progression and disc hemorrhage in glaucoma in a 3-year prospective study [published online August 21, 2020]. Ophthalmol Glaucoma. doi:10.1016/j.ogla.2020.08.008