Features of the Lamina Cribrosa and the Autonomic Nervous System in Glaucoma Patients with Disc Hemorrhages

PURPOSE: To assess the effects of structural changes in the lamina cribrosa (LC) and the status of the autonomic nervous system on disc hemorrhages (DHs). METHODS: A retrospective study was performed on 68 eyes of 68 patients with primary open-angle glaucoma and optic DHs. We divided the patients into two groups using optical coherence tomography according to the presence of LC defects, and then compared both groups. We also analyzed autonomic nervous system function using the heart rate variability test, and compared the two groups. RESULTS: Eyes with LC defects had significantly longer axial lengths than those without defects (p = 0.029), and the DH was located more proximally (p < 0.001). A significantly larger proportion of eyes without LC defects had configurational optic disc changes such as optic disc rim notching, focal rim thinning, or generalized thinning (p = 0.001). On heart rate variability testing, the group without LC defects had a significantly higher “low frequency/high frequency ratio” than the group with defects (p = 0.008). CONCLUSIONS: There was a difference in the clinical features of DH between eyes with and without LC defects. Eyes with LC defects were more myopic and the proximal part of the DH tended to be on the disc cup or characterized by peripapillary atrophy. These results suggest that the DH developed due to a mechanical cause in eyes with LC defects. Patients without LC defects had a more dysregulated autonomic nervous system. The DH location was related to disc rim notching and neural rim losses, which implies ischemia as the pathogenic mechanism involved in the development of DH in eyes without LC defects. Therefore, more careful observations of the LC would facilitate a better understanding of the specific pathogenic mechanisms underlying DH.

The Correlations between Recurrent Disc Hemorrhage and Sympathetic Variability, and the Disc Morphology

PURPOSE: To evaluate the correlations of sympathetic variability and recurrent disc hemorrhage, and the morphology of the optic disc. METHODS: This study included 41 eyes of 41 patients who had at least one disc hemorrhage (DH), who were diagnosed with open-angle glaucoma or suspected glaucoma. All eyes had a DH at presentation and were followed-up for at least 3 years. Eyes were classified by the morphology of the optic disc into the focal rim thinning, concentric cupping, or myopic disc groups. The variability of the sympathetic nervous system was defined by the Standard deviation of all node to node intervals (SDNN) as very low frequency, low frequency (LF), or high frequency, which was the standard parameter of heart rate variabilities. RESULTS: There were 14 (34.14%) eyes with a single DH, and the remaining eyes with a recurrent DH. Single DH patients tended to have a myopic disc (p < 0.001) and, especially in the lower 50% of the SDNN group, the recurrent DH group had a lower SDNN (p = 0.046), and a higher LF (p = 0.002). CONCLUSIONS: DH recurred when patients had morphological glaucomatous changes, especially focal rim thinning. Differences of the sympathetic variability had a strong correlation with the recurrent DH.

Comparison of the Progression of High- and Low-tension Glaucoma as Determined by Two Different Criteria

PURPOSE: To investigate and compare the progression of medically treated primary open angle glaucoma according to the baseline intraocular pressure (IOP). METHODS: This study included a total of 345 eyes from 345 patients (mean follow-up period, 4.5 years). Eyes were classified into either conventional normal tension glaucoma (cNTG, 21 mmHg) groups according to the conventional cut-off value of the IOP. Additionally, the median IOP (15 mmHg) was used to create two other groups (median NTG [mNTG] 15 mmHg). Using these values, 306, 39, 153, and 192 eyes were assigned to the cNTG, cHTG, mNTG, and mHTG groups, respectively. Glaucoma progression was determined either by optic disc/retinal nerve fiber layer photographs or serial visual field data. RESULTS: Mean reduction of IOP after medical treatment and of central corneal thickness was lower in the cNTG group, while the prevalence of disc hemorrhage and baseline visual field mean deviation did not differ between the cNTG and cHTG groups. A mean reduction in the IOP was observed after medical treatment, and central corneal thickness was lower in the mNTG group; disc hemorrhage was more frequent in the mNTG than in the mHTG group. Among the 345 analyzed eyes, 100 (29%) showed progression during the follow-up period. In the cHTG group, a higher baseline IOP (hazard ratio, 1.147; p = 0.024) was associated with glaucoma progression. Disc hemorrhage (hazard ratio, 15.533; p < 0.001) was also strongly associated with progression in the mNTG group. CONCLUSIONS: Baseline IOP was a significant risk factor for glaucoma progression in cHTG patients (10% of our total participants), while disc hemorrhage showed the strongest association with progression in the mNTG group, indicating that a cut-off value other than the conventional 21 mmHg is required to define true low-tension glaucoma in populations where NTG predominates among all glaucoma patients.

A Case of Optic Disc Hemorrhage Associated with Buried Optic Nerve Head Drusen

PURPOSE: We report a case of optic disc hemorrhage associated with buried optic nerve head drusen in a pediatric patient. CASE SUMMARY: A 10-year-old female visited our clinic with a floating sensation in her left eye, 2 days in duration. Best corrected visual acuity was 1.0 in both eyes. Intraocular pressure, light reflex, relative afferent pupillary defect and color vision were normal. The patient showed a small optic disc with blurred, irregular margins in both eyes, and optic disc hemorrhage in the left eye on fundus examination. Visual field examination revealed an enlarged blind spot in the left eye. To achieve correct diagnosis, brain MRI was performed and revealed normal findings. On spectral-domain optical coherence tomography (OCT), hyper-reflective and heterogeneous mass like lesions were found with buried optic nerve head drusen. CONCLUSIONS: In general, optic nerve head drusen, has a good prognosis; however, visual field defects or hemorrhagic complications can occur, therefore, correct diagnosis and regular follow-up are necessary.

Intra-individual, Inter-ocular Comparison In Normal Tension Glaucoma with Unilateral Field Loss

PURPOSE: To investigate whether there are differences in ocular risk factors reportedly associated with the development of normal tension glaucoma (NTG) between glaucomatous eyes and normal visual field (VF) eyes of monocular NTG patients. METHODS: Thirty-six patients who had NTG in one eye and normal RNFL and VF in the fellow eye were included in this hospital-based cross-sectional retrospective survey. We analyzed the difference between glaucomatous eyes and normal VF eyes according to an intra-individual, inter-ocular comparison of ocular parameters, including intraocular pressures (IOP), central corneal thickness (CCT), optic disc size, myopia, optic disc hemorrhage, and zone beta of peripapillary atrophy. Measurements of optic disc size and area and the angular and radial extent of zone beta were obtained using a Heidelberg Retina Tomograph. We also evaluated the correlation of each parameter with mean deviation (MD) and pattern standard deviation (PSD). RESULTS: There were no inter-ocular differences of IOP, CCT, optic disc size, or myopia (n=36). Optic disc hemorrhage was found in only three glaucomatous eyes. The area of zone beta was greater in glaucomatous eyes than in normal VF eyes (p=0.003). No parameters were correlated with MD or PSD. CONCLUSIONS: Except for optic disc hemorrhage and zone beta area, all other parameters showed no inter-ocular differences. The asymmetry of disc hemorrhage and zone beta area in monocular NTG patients implies that optic disc ischemia might play a role in the pathogenesis of NTG.

Disc Hemorrhages in Patients with both Normal Tension Glaucoma and Branch Retinal Vein Occlusion in Different Eyes

PURPOSE: To document the clinical features of disc hemorrhage in patients with branch retinal vein occlusion (BRVO) and normal tension glaucoma (NTG), and to evaluate the relationship between BRVO and NTG with disc hemorrhages. METHODS: From July 2001 to May 2006, sixteen patients with both NTG and BRVO in different eyes were successively collected from outpatient population of Seoul National University Hospital in this observational case series. The frequency and location of disc hemorrhages, history of associated systemic diseases, and the order of the time of diagnosis between NTG and BRVO were studied. RESULTS: All patients had unilateral BRVO, and their mean age was 63.3+/-10.6 years. Disc hemorrhages were detected in eight patients (50%) during the mean follow-up of 26.8 months (range, 3-96 months). Six patients (75%) had disc hemorrhages in the non-BRVO eyes and two patients (25%) in BRVO eyes. Five hemorrhages (62.5%) were located at inferior-temporal quadrant of the optic disc. History of systemic hypertension was identified in 12 patients (75.0%). In 11 patients (68.8%), NTG was diagnosed at the same time as BRVO. CONCLUSIONS: A higher frequency of disc hemorrhages was identified in patients with both BRVO and NTG. Therefore, some cases of NTG, especially with disc hemorrhages, may share a common vascular pathophysiology with BRVO.

Comparison of Clinical Characteristics and Progression of Glaucoma between Recurrent and Non-recurrent Optic Disc Hemorrhage

PURPOSE: To compare the clinical characteristics and the progression rate of glaucoma between the patients with recurrent and non-recurrent optic disc hemorrhages. METHODS: The medical records of 31 eyes 28 patients with optic disc hemorrhage were retrospectively reviewed. The patients had been followed up regularly with 1-3 months interval between 1991 and 2002 for more than 1 year after the first hemorrhage. Non-recurrent group was defined as having one episode of disc hemorrhage while recurrent group as having two or more episodes of hemorrhages. RESULTS: Sixteen eyes (51.6%) showed recurrent and fifteen eyes (48.4%) showed non-recurrent hemorrhages. Normal tension glaucoma was the most common type of glaucoma in both recurrent and non-recurrent group. Inferotemporal area was the most common location of disc hemorrhage in both groups. There were no differences in prevalence of associated systemic diseases between both groups. Recurrent group (43.8%) had more progressive change of optic disc than non-recurrent group (13.3%) with a borderline statistical difference (P=0.07). The concordance between the location of disc hemorrhage and retinal nerve fiber layer defect was higher in recurrent group than non-recurrent group (P=0.09). Progressive change of visual field was not different between both groups (P=1.00). CONCLUSIONS: Recurrent group showed more progressive change of optic disc than non-recurrent group. However, visual field change showed no difference between 2 group. Further study must be made with a large number of patients and longer follow-up period.

Correlation Between Disc Hemorrhage and Peripapillary Atrophy in Glaucoma Patients with Unilateral Disc Hemorrhage

PURPOSE: To investigate the correlation of peripapillary atrophy with disc hemorrhage in glaucoma patients with a unilateral disc hemorrhage METHODS: A retrospective review was performed on the medical records of 36 glaucoma patients (7 with primary open-angle glaucoma and 29 with normal-tension glaucoma) with a unilateral disc hemorrhage during a mean follow-up period of 25 months. Topographic measurements were performed with Heidelberg Retina Tomograph (HRT) within three months of detection of a disc hemorrhage. The parameters of zone beta of peripapillary atrophy were analyzed by the atrophy zone analysis program and compared with the fellow eyes. RESULTS: The area, angular and radial extent of zone beta, and ratio of zone beta area to disc area were significantly greater in the hemorrhagic eyes than in the contralateral eyes. The difference of refractive error, intraocular pressure, MD and CPSD of visual fields was not found to be significant between both eyes. CONCLUSIONS: The area and extent of peripapillary atrophy was significantly greater in the eyes with disc hemorrhage compared to the contralateral control eyes. This study suggested quantitatively that the peripapillary atrophy is associated closely with disc hemorrhage in glaucoma patients.

Clinical Course of the Eyes with Retinal Nerve Fiber Layer Defect and Normal Visual Field

PURPOSE: To investigate the clinical course of eye with retinal nerve fiber layer (RNFL) defect without visual field (VF) defect, and to assess the risk factors for the progression of RNFL defect and the development of VF defect. METHODS: We performed retrospective chart review of the patients who had had RNFL photography and Humphrey visual field test. The seventy six eyes of 76 patients showed RNFL defect with normal VF. RESULTS: The average follow-up period was 36.6 months. Among the 76 eyes, 64 eyes (84%) showed neither the progression of RNFL defect nor the development of VF defect. Six eyes (8%) showed progression of RNFL defect without VF deterioration and 4 eyes (5%) showed development of VF defect without progression of RNFL defect. Two eyes (3%) showed both progression of RNFL defect and development of VF defect. The progression of RNFL defect was significantly related to the disc hemorrhage and the number of anti-glaucoma medications and less significantly to intraocular pressure (IOP) fluctuation (p=0.051). The development of VF defect was related to the number of anti-glaucoma medications. CONCLUSIONS: The majority (84%) of eyes with RNFL defect but normal VF did not show any sign of glaucomatous progression for average 36.6 months. The VF defect developed in 8% and the RNFL defect progressed in 11%. The factors related to progression of RNFL defect were the disc hemorrhage, the number of anti-glaucoma medications and IOP fluctuation. The factors related to the development of VF defect was the number of anti-glaucoma medications.

Correlation of Peripapillary Atrophy with Optic Disc Cupping and Disc Hemorrhage in Primary Open Angle Glaucoma

To investigate the correlation of peripapillary atrophy with optic disc dupping and disc hemorrhage in primary open angle glaucoma(POAG) patients, tomographic measurements were performed with Heidelberg Retina Tomograph(HRT, Heidelberg Engineering, Germany). We analyzed cup to disc area ratio(C/D ratio) and peripapillary atrophy to disc area ratio(P/D ratio) from 28 eyes of 14 POAG patients with peripapillary atrophy(Group A), only C/D ratio from 28 eyes of 14 POAG patients without peripapillary atrophy(Group B), and only P/D ratio from 28 eyes of non-glaucomatous subjects with peripapillary atrophy(Group C). Group A was subclassified into thos with disc hemorrhage (Group A-1) and those without dixd hemorrhage(Group A-2), and changes of visual field defects were also analyzed from each subgroup witn Humphrey automated perimetry (Allergan Humphrey, USA, C24-2) at the six-month follow-up. Cup to disc area ratio(0.54+/-0.160)in the Group A was signifcantly higher than that(0.406+/-0.130) in the Group B, and P/D ratio was higher in Group A(0.619+/-0.203) than in the Group C(0.484+/-0.130). P/D ratio was also higher in Group A-1(0.725+/-0.34) than in the Group A-2(0.605+/-0.273). There was no significant difference in mean deviation(M/D) and corrected pattern standard deviation(CPSD) between Group A-1 and Group A-2. The results led us to the conclusion that peripapillary atrophy had significant correlation with glaucomatous damage on optic disc and disc hemorrhage in glaucoma patients. Therefore more attention should be paid tod a glaucoma patient especially when he or she presents with peripapillary atrophy.