Optic disc hemorrhage is a splinter or flame-shaped hemorrhage oriented perpendicular to the optic disc margin. It is located in the prelaminar optic disc and extends across the peripapillary zone into the adjacent superficial retinal nerve fiber layer (RNFL). Deeper hemorrhages may appear round and blot-shaped.
Disc hemorrhage occurs specifically in optic discs with glaucomatous changes and is more frequent in normal-tension glaucoma. The predilection sites are the inferotemporal and superotemporal disc regions, and about 80% coincide with the location of rim notching (localized excavation) or retinal nerve fiber layer defects.
Disc hemorrhage can also occur in eyes without signs of glaucoma, but in glaucomatous eyes it serves as an indicator of disease progression 1). It is recommended to actively look for disc hemorrhage during clinical examination 3).
QCan you notice disc hemorrhage yourself?
A
There are no subjective symptoms, so it is difficult to notice on your own. It is mostly discovered incidentally during fundus examination, and regular eye exams are important. In the OHTS study, only 16% of disc hemorrhages detected on clinical examination were found, while 84% were first discovered on fundus photograph review at a reading center 2).
Disc hemorrhage itself causes no subjective symptoms. If visual acuity loss or visual field abnormalities are noticed, they are due to the progression of underlying glaucoma, not the hemorrhage itself.
Hemorrhage morphology: Linear (splinter type) or flame-shaped hemorrhage oriented perpendicular to the disc margin. Hemorrhage may be confined to the peripapillary RNFL within one disc diameter from the disc.
Predilection site: inferotemporal and superotemporal. The 7 o’clock position is most common. In a study of 128 eyes with primary open-angle glaucoma, 58.0% were in the inferior sector of the inferotemporal quadrant, and 40.6% were located at the disc margin.
Duration: 2 to 35 weeks (mean 6 to 12 weeks)
Recurrence: Recurrence was observed in 64% of eyes, of which 92% occurred within 28 weeks of the previous hemorrhage.
Size difference: In cases with normal baseline intraocular pressure, larger and longer hemorrhages are observed compared to cases with ocular hypertension.
The prevalence in the general population is 0.6–1.4%. It was 1.4% in the Blue Mountains Eye Study, 0.9% in the Beaver Dam Eye Study, and 0.6% in a large-scale screening in Japan.
The frequency differs by glaucoma type. In the Blue Mountains Eye Study, 13.8% of participants with open-angle glaucoma (OAG) had disc hemorrhage. The breakdown was 8% in high-tension glaucoma and 25% in low-tension glaucoma. In normal-tension glaucoma (NTG), the frequency is high at 20.5–33.3%. Overall, it is observed more frequently in early-stage glaucoma than in advanced stages, and more often in NTG than in high-tension glaucoma.
The exact mechanism of disc hemorrhage is unknown, but two main hypotheses have been proposed: the “mechanical hypothesis” and the “vascular hypothesis.” For details on pathophysiology, see the section “Pathophysiology and Detailed Mechanism”.
Ocular Local Factors
Increased vertical cup-to-disc ratio: The larger the cup-to-disc ratio, the higher the risk2)
Thin central corneal thickness (CCT): Identified as a risk factor in the 13-year analysis of the OHTS2)
Peripapillary atrophy (PPA): The presence and area of β-zone PPA are significantly associated with DH.
Decreased peripapillary choroidal vascular density: OCTA studies have confirmed choroidal microvascular dropout spatially coinciding with the site of disc hemorrhage.
Low mean ocular perfusion pressure: A risk factor for the development of disc hemorrhage in patients with normal-tension glaucoma.
Systemic Factors
Aging: Consistently significant association in multiple population-based studies1)
Female sex: Significant association reported in multiple studies3)
Vascular disease: Association reported with angina, myocardial infarction, and stroke2)
Systemic hypertension: Both supporting and refuting reports exist
Seasonal temperature changes: Low temperature may cause increased intraocular pressure and decreased ocular blood flow, leading to higher incidence in winter
Optic disc hemorrhage is a representative risk factor for glaucoma, and progression of visual field damage is rapid after its appearance. It is more frequent in NTG than in primary open-angle glaucoma, and the frequency of visual field damage within the central 10° is also higher. It is considered a sign requiring more aggressive treatment1).
Systemic Factors
Main Reports
Aging, Female sex
Consistent across multiple large-scale studies
Vascular disease
Healey, Budenz
Migraine
Healey, Furlanetto
QDoes optic disc hemorrhage always mean glaucoma?
A
Not necessarily. In the Blue Mountains Eye Study, 70% of optic disc hemorrhages were observed in eyes without glaucoma. However, the presence of optic disc hemorrhage is associated with an increased risk of developing glaucoma2), and even if it does not meet the diagnostic criteria for glaucoma at the time of detection, it may progress later. If optic disc hemorrhage is found, it is important to undergo a thorough examination for glaucoma.
Observation of the optic disc and peripapillary retina is performed using a high-magnification pre-corneal lens (e.g., 78D, 90D) and a slit-lamp microscope 4). Findings are described, the location of the optic disc hemorrhage is illustrated, and fundus photographs are taken.
Clinical examination alone often misses many cases. In the OHTS, the detection rate in clinical practice was only 16%, while 84% were detected by annual photographic review at a reading center 2). An active search for optic disc hemorrhage is important 3).
Fundus photography is one of the most effective methods for recording and following up optic disc hemorrhage 4). Stereoscopic photography is desirable. Photographs centered on the optic disc with an angle of about 30° are suitable.
Current optic disc imaging technologies such as OCT cannot reliably identify optic disc hemorrhage. Imaging is positioned as an adjunct to clinical examination.
Research is being conducted on detecting optic disc hemorrhage from fundus photographs using artificial intelligence (AI) and deep learning. Some models have reported sensitivity and specificity comparable to clinicians, but they are not yet in clinical use.
Non-arteritic anterior ischemic optic neuropathy (NA-AION): Peripapillary hemorrhage with optic disc edema is frequently observed5)
Posterior vitreous detachment (PVD): Often flame-shaped (60.9%), located on the nasal side, and tends to be larger in area. Glaucomatous DH is more often splinter-shaped (92.3%)
There is no treatment for the optic disc hemorrhage itself. The hemorrhage typically resolves spontaneously within an average of 6 to 12 weeks.
Detection of optic disc hemorrhage prompts the following clinical actions:
Comprehensive glaucoma evaluation: Individuals with optic disc hemorrhage are considered glaucoma suspects2)
Enhanced visual field monitoring: Regular visual field testing to assess progression1)
Consideration of intraocular pressure lowering therapy: In known glaucoma patients, optic disc hemorrhage is a sign of disease activity or progression, providing a rationale to initiate or intensify intraocular pressure lowering therapy1)
The presence of optic disc hemorrhage is one factor that justifies setting a lower target intraocular pressure1). It should be considered together with the severity of optic nerve damage, rate of progression, family history, age, and other factors.
QIs there a treatment for optic disc hemorrhage?
A
There is no treatment for optic disc hemorrhage itself, and the hemorrhage resolves spontaneously over several weeks to months. The important thing is the management of the underlying glaucoma. If optic disc hemorrhage is found, a detailed glaucoma examination should be performed, and intraocular pressure-lowering treatment should be initiated or intensified as needed1).
This hypothesis proposes that hemorrhage occurs due to mechanical shear forces at the lamina cribrosa, or damage to the capillary network at the expanding border of RNFL defects. The primary insult is neurodegeneration, and traction due to connective tissue changes, lamina cribrosa remodeling, and glial scar formation damages the microvasculature, leading to secondary hemorrhage.
It is based on the theory that intraocular pressure-related compression and tension (stress and strain) on connective tissue have pathophysiological effects on optic nerve head tissues such as the lamina cribrosa, axons, and vascular endothelial cells.
This hypothesis proposes that primary vascular disorders, such as ischemic microinfarction in the optic nerve head or breakdown of the blood-retinal barrier, cause hemorrhage.
In studies using OCT angiography (OCTA), 46.3% of eyes with optic disc hemorrhage showed peripapillary choroidal microvascular dropout at the hemorrhage site, compared to 29.4% of eyes without hemorrhage. Furthermore, densitometry studies suggest that the blood in optic disc hemorrhage may be of arterial origin.
Open-angle glaucoma eyes with optic disc hemorrhage have significantly lower peripapillary choroidal vascular density compared to open-angle glaucoma eyes without hemorrhage. The choroidal defect areas are localized and often spatially coincide with the site of optic disc hemorrhage.
Positioning as an intraocular pressure-independent factor
Optic disc hemorrhage is a representative intraocular pressure-independent risk factor for glaucoma. It is closely associated with the most representative and evidence-based local and systemic circulatory disorders, and is positioned alongside factors such as peripapillary atrophy (PPA), low ocular perfusion pressure, and low diastolic/systolic blood pressure.
In a study of 33 eyes, all eyes with a pre-existing neural rim notch subsequently developed disc hemorrhage at or adjacent to the notch site. The observation that rim notches precede disc hemorrhage (mean 21.5 months) and that hemorrhage occurs at or near the notch site supports the theory that glaucomatous damage begins before the appearance of hemorrhage.
13-year follow-up analysis2): The cumulative incidence of primary open-angle glaucoma in eyes with disc hemorrhage was 25.6% (vs. 12.9% without hemorrhage). Multivariate analysis showed that the presence of DH increased the risk of developing primary open-angle glaucoma by 3.7 times.
DH detection rate: Detection in clinical settings was only 16%, while 84% were detected by photographic review at a reading center2).
Incidence in OHT patients: Low at 0.5%/year, but doubled to 1.2%/year after developing primary open-angle glaucoma.
Other Large-Scale Trials
CNTGS (Collaborative Normal-Tension Glaucoma Study): Patients with DH at enrollment had a 2.72 times higher probability of reaching a visual field endpoint.
EMGT (Early Manifest Glaucoma Trial)3): DH frequency was higher in patients with low intraocular pressure, female sex, and myopia; no treatment effect was observed. Over 15 years of follow-up, DH was confirmed as a risk factor for progression.
AAO Primary Open-Angle Glaucoma PPP1): Both the presence of DH and the proportion of DH at visits were associated with progression of visual field loss or optic nerve damage. Reported in both normal-tension and high-tension glaucoma.
Recent reviews discuss the possibility that disc hemorrhage is not a risk factor causing onset but rather an indicator of ongoing glaucomatous damage. There is a view that undetectable early axonal loss occurs before disc hemorrhage appears, and that hemorrhage occurs as a result of glaucoma progression. Another theory suggests that hemorrhage occurs due to capillary destruction during the expansion of RNFL defects.
AI methods to improve fundus photograph quality and assist in detecting disc hemorrhage are being studied. Some models report sensitivity and specificity comparable to clinicians, but clinical implementation has not yet been achieved.
QWhat should I do if optic disc hemorrhage is found?
A
First, it is important to undergo a comprehensive glaucoma examination (including intraocular pressure measurement, gonioscopy, visual field testing, OCT, etc.) 2). If already diagnosed with glaucoma, increase the frequency of visual field testing and consider intensifying intraocular pressure-lowering treatment. Optic disc hemorrhage itself resolves spontaneously within weeks to months, but it may indicate glaucoma progression, so regular follow-up is necessary.
