Optic Disc Hemorrhage Research Articles

Scanning laser polarimetry and detection of progression after optic disc hemorrhage in patients with glaucoma.

To examine retinal nerve fiber layer changes with scanning laser polarimetry (SLP) in the eyes of patients with glaucoma and optic disc hemorrhage. Automated perimetry and SLP were performed in 17 eyes of 17 patients identified prospectively with optic disc hemorrhage. Criteria for visual field progression were based on decreased sensitivity seen at 3 adjacent points on the total deviation plot. Progression on SLP images was defined as a 15% or more decrease in the average thickness of the affected quadrant (superior or inferior), a 25% or more reduction in the affected quadrant ratio, an increase in the nerve fiber analyzer number of 10 or more (GDx Nerve Fiber Analyzer; Laser Diagnostic Technologies), or any change on Serial Analysis of the SLP images. Visual field progression and SLP image progression. The mean follow-up was 31 months (minimum, 12 months). Of the 17 eyes, 10 (59%) had visual field progression. No significant change was seen on SLP images for either the total group or the group with visual field progression. Five eyes (29%) showed progression on SLP images, 3 of which also showed visual field progression. Ten eyes showed progression on SLP images that was not confirmed on subsequent imaging. In eyes with visual field progression after optic disc hemorrhage, a significant change in the SLP image was not seen. Fluctuation of SLP results in patients with glaucoma necessitates confirmation of progression seen on SLP images.

Glaucoma diagnosis of the optic disc using photography and planimetry

Ophthalmoscopically and on clinical optic disc photographs, the optic nerve head can be described by the following parameters: size and shape of the optic disc, size and shape of the neuroretinal rim, size and shape of the optic cup, size and shape of the alpha and beta zones of parapapillary chorioretinal atrophy, visibility of the retinal nerve fiber layer, diameter of the retinal arteries, presence and location of optic disc hemorrhages.

Inter-eye differences in chronic open-angle glaucoma patients with unilateral disc hemorrhages

Objective Flame-shaped optic disc hemorrhages are a hallmark of glaucomatous optic neuropathy. The purpose of this study was to evaluate which parameters differ between companion eyes with and without an optic disc hemorrhage in patients with chronic open-angle glaucoma. Design Comparative (companion eye) observational case series. Patients The study included 99 white patients with bilateral chronic open-angle glaucoma and unilateral flame-shaped optic disc hemorrhages. Methods All patients underwent qualitative and morphometric evaluation of color stereo optic disc photographs. Main outcome measures Size and shape of the optic disc, neuroretinal rim and parapapillary atrophy, diameter of the retinal vessels, intraocular pressure measurements, and both mean value and loss variance value of the visual field examination. Results In an intraindividual inter-eye comparison, the eyes with disc hemorrhages and the contralateral eyes without disc bleeding did not vary significantly ( P > 0.20) in size and shape of the optic disc and neuroretinal rim, optic cup depth, size of alpha and beta zone of parapapillary atrophy, retinal vessel diameter, intraocular pressure measurements, refractive error, and perimetric indices. Conclusions In bilateral chronic open-angle glaucoma, the development of unilateral optic disc hemorrhages does not depend on inter-eye differences in size and shape of the optic disc, neuroretinal rim and parapapillary atrophy, diameter of the retinal vessels, intraocular pressure measurements, or visual field loss.

Small neuroretinal rim and large parapapillary atrophy as predictive factors for progression of glaucomatous optic neuropathy

PurposeTo evaluate which morphologic features of the optic disc are predictive factors for progressive neuroretinal rim loss in chronic open-angle glaucoma. DesignProspective, observational case series. ParticipantsThe study included 394 eyes of 257 white patients with chronic open-angle glaucoma. Mean follow-up time was 31.8 months (median, 39.7 months). Progression of glaucoma was defined as loss of neuroretinal rim as detected by disc photographs. Presence of optic disc hemorrhages was not taken into account. MethodsAll patients underwent repeated qualitative and morphometric evaluation of color stereo optic disc photographs. Statistical analysis included Kaplan-Meier curves, and bivariate and multivariate Cox regression analysis adjusted for patients’ ages. Dependency of left and right eyes from the same subject was taken into account. Main outcome measuresQualitative and quantitative morphologic optic nerve head parameters. ResultsProgression of glaucomatous optic nerve changes was detected in 42 eyes (11%). At baseline of the study, neuroretinal rim area (total area, P = 0.03) was significantly smaller, and β zone of parapapillary atrophy (total area, P = 0.04) was significantly larger in the progressive study group compared with the nonprogressive study group. Neither study group varied significantly in size and shape of the optic disc, optic cup depth, α zone of parapapillary atrophy, and diameter of the retinal arteries and veins (P > 0.05). Multiple Cox regression analysis revealed that the progression of glaucoma depended significantly on the area of the neuroretinal rim (temporal sector, P = 0.003) and β zone of parapapillary atrophy (temporal inferior sector, P = 0.02). ConclusionsImportant morphologic predictive factors for progression of the glaucomatous appearance of the optic nerve head in white persons are small size of neuroretinal rim and large area of β zone of parapapillary atrophy. Progression of glaucomatous optic nerve head changes is independent of size and shape of the optic disc, size of α zone of parapapillary atrophy, retinal vessel diameter, and optic cup depth.

Medical backgrounders: glaucoma.

Glaucoma is a leading cause of irreversible blindness in the world. Currently, glaucoma is diagnosed as a progressive optic neuropathy with characteristic optic disc and nerve fiber layer damage, usually associated with loss of visual function. The intraocular pressure (IOP) is the most important risk factor for the disease, although a significant proportion of patients do not have elevated IOP. Other risk factors include older age, African descent, myopia and family history of the disease. The ophthalmoscopic examination of the optic disc is essential to identify the signs of glaucomatous optic neuropathy, such as increased cupping, neuroretinal rim thinning or optic disc hemorrhages. Glaucomatous visual field loss usually starts in the periphery, and loss of central vision does not occur until late in the course of the disease. Visual function is most commonly assessed by standard automated perimetry; however, as many as 50% of nerve fibers can be lost before the appearance of visual field defects in this test. Newer technologies have been developed to find more sensitive ways to detect early glaucoma using both functional (short-wavelength automated perimetry and frequency-doubling perimetry) and structural (scanning laser topography, optical coherence tomography and scanning laser polarimetry) measurements. The management of glaucoma is based on lowering the intraocular pressure to prevent further optic nerve damage. Currently, there are five major classes of medications that are used to lower the intraocular pressure: Beta-adrenergic antagonists, adrenergic agonists, parasympathomimetics, prostaglandin-like analogues and carbonic anhydrase inhibitors. The goal of therapy is to maintain adequate vision for patients during their lifetime, keeping in mind the possible adverse effects of the drugs. If additional lowering of IOP is indicated or if medication fails to sufficiently lower the IOP, laser trabeculoplasty is usually the next step. If IOP is still not adequately controlled, incisional glaucoma surgery is indicated. Neuroprotective agents, which directly protect the optic nerve in glaucoma, are being evaluated in clinical trials.

Optic disc, foveal, and extrafoveal damage due to surgical separation of the vitreous.

To evaluate the morphologic outcomes resulting from surgical vitreoretinal separation in young adult primates. Vitrectomy and mechanical separation of the vitreous from the internal limiting lamina (ILL) of the posterior retina and surface of the optic disc were performed on 25 young adult cynomolgus monkey eyes in vivo. Lectin histochemical studies were used to evaluate the vitreoretinal interface. Morphologic outcomes were tabulated. In 11 of 25 eye regions, residual vitreous remained attached to the ILL in some of the regions. Localized ILL breaks or separation of the ILL from the neural retina was noted in 9 eyes. Retinal tissue loss, including avulsion of the ganglion cell, inner plexiform, or inner nuclear layers, was observed in 7 eyes. Avulsion of axon bundles in the optic disc was noted in 9 eyes. Significantly, partial- or full-thickness foveal tears were noted in 11 eyes. Based on the surgeons' intraoperative observations, small superficial optic disc or retinal hemorrhages were observed in 3 of 25 eyes. None of the eyes on which a vitrectomy alone was performed showed ILL damage, or retinal or optic disc tissue loss. Damage may occur to the optic disc, fovea, and extrafoveal retina as a result of surgical separation of the vitreous from the retina in young adult primates. These data support the contention that surgically induced damage at the level of the vitreoretinal interface may help explain the visual field defects noted after surgery to close full-thickness macular holes. These data also support the need for developing additional modalities to assist in vitreous separation, thereby reducing the risk of traumatic complications associated with purely mechanical procedures.

Blood Flow in Retinal Vessels of Normal-tension Glaucoma with or without a History of Optic Disc Hemorrhages

To evaluate blood flow in retinal vessels of normal-tension glaucoma (NTG) with or without a history of optic disc hemorrhages (DH) and compare it with that in non-glaucomatous eyes using scanning laser fluorescein video angiography. We enrolled 14 eyes of 14 NTG patients with a history of DH (DH (+) group), 12 eyes of 12 NTG patients without history of DH (DH (-) group), and 10 eyes from 10 non-glaucomatous patients matched for age, intraocular pressure, and systemic blood pressure. No statistically significant difference was observed between the DH (+) and DH (-) groups of NTG in the global indices of the Humphrey visual field. Fluorescein angiography was performed using a scanning laser ophthalmoscope with an argon blue laser. A series of approximately 100 consecutive video images at 1/2 second intervals from just before the dye appearance in the central retinal artery was loaded into an external personal computer system. Based on this acquired image series, we obtained fluorescein filling curves for 10 x 10 pixel measuring areas placed on each of the superior-temporal and inferior-temporal branch retinal arteries and veins at 1/5 papillary diameter from the disc edge. In each vessel, time to the highest fluorescein intensity (peak time, sec) and the time constant of the filling curve (tau, sec) were obtained. Time difference between the peak times in vein and artery (peak time difference) was also calculated. Statistically significant differences were observed among the three groups in the peak time of inferior-temporal artery and vein, and superior-temporal vein (ANOVA, p < 0.01). Also there were statistically significant differences in the tau of all vessels (ANOVA, p < 0.05). No statistically significant differences were observed in the peak time differences. By multivariate analysis, the DH (+) and DH (-) groups of NTG showed significantly longer peak times and tau s than did the non-glaucomatous eyes (p < 0.05). However, no statistically significant differences were observed in any parameters between the DH (+) and DH (-) groups of NTG. In NTG, dye filling rate in both the central retinal arteries and veins seems to be delayed. However, this delay does not differ between DH (+) and DH (-) groups.

Papillary hemodynamics in patients with normal pressure glaucoma and hemorrhage of the optic papilla circumference

Optic disc hemorrhages in patients with normal-pressure glaucoma (NPG) are usually regarded as a sign of vascular dysfunction and as an indicator for glaucoma damage progression. Optic nerve head blood flow was measured in 21 patients suffering from NPG with acute optic disc hemorrhages by scanning laser Doppler flowmetry at various locations of the optic disc. Intraocular pressure and mean deviation of the visual field were also monitored. Two groups served as control: 21 patients with NPG matched for age, sex, and stage of the disease and in addition the contralateral eye without any hemorrhages. Optic nerve head blood flow as a mean of several locations was significantly lower in eyes with optic disc hemorrhages than in controls and differed significantly from the contralateral eye. Optic nerve blood flow was lower in NPG eyes with optic disc hemorrhages than in the contralateral eye and in controls.

Monitoring of morphometric changes of optic discs with morphologic progression of glaucomatous optic atrophy by means of laser scanner tomography

Aim of this study was to measure morphometric changes in optic discs with laser-scanning tomography (HRT, Heidelberg-Retina-Tomograph, Heidelberg) in eyes with early glaucomatous morphologic progression. 61 eyes of 36 patients with marked neuroretinal rim loss or its early morphologic signs (1. optic disc hemorrhages, 2. reduced visibility of the retinal nerve fiber layer (RNF), 3. appearance of narrowing of retinal vessels, 4. enlargement of the choroidal, parapapillary atrophy) were compared to 74 normal eyes of 39 probands. 15 degrees stereographs of the optic discs were evaluated for morphologic changes. The morphometric variables of the neuroretinal rim and excavation measured by the HRT were examined in the course of the disease. In the group of normals no significant changes of the neuroretinal rim in the course of 2.0 +/- 1.2 years were found. In the group of glaucomatous eyes (3.0 +/- 1.5 years follow-up) 34 eyes showed marked neuroretinal rim loss, 17 disc hemorrhages, 4 vessel narrowing, 3 an increased chorioidal atrophy, 3 a decreased visibility of the retinal nerve fiber layer. In these eyes a significant loss of rim area (p = 0.01) and an increase of excavation area (p = 0.0001) and volume (p = 0.003) was measured by the HRT. Only three eyes showed a perimetric loss of sensitivity (0.8-3.4 db) in Octopus static perimetry. Laser-scanning tomography of the optic disc seems to be able to measure morphometric changes in eyes with morphologic progression of glaucomatous optic atrophy, even before perimetric changes occur.

The optic nerve head in normal-tension glaucoma.

There is controversy over the definition, appearance, and characteristics of the optic nerve head in normal-tension glaucoma (NTG). Optic disk size is greater in eyes with NTG than in those with primary open-angle glaucoma. However, in an intraindividual bilateral comparison, the eye with the larger optic disk showed neither more marked nor less pronounced glaucomatous optic nerve damage. Optic disk hemorrhage and peripapillary atrophy have been reported to be more frequent in patients with NTG. Nonuse of calcium channel blockers, peripapillary atrophy, and disk hemorrhage were statistically significantly associated with visual field loss progression in NTG. However, there is a possibility that a high IOP may stop disk hemorrhage relatively early. Histopathologic optic nerve head changes correlated with the clinical appearance of the optic nerve head, which is comparable in NTG and primary open-angle glaucoma. However, as novel findings, serum antibodies to retinal proteins and retinal immunoglobulin deposition in the ganglion cells were observed, and the level of serum autoantibodies to optic nerve head glycosaminoglycans was higher in patients with NTG than in patients with primary open-angle glaucoma.

Exfoliation syndrome and exfoliation glaucoma.

Exfoliation syndrome abnormal deposition in the anterior segment of the eye of an unknown substance thought to be related to elastic fibres and basement membrane components is associated with accelerated cataract progression. increased frequency of intraoperative and postoperative complications and increased risk for glaucoma and. therefore, is a clinically important finding. A clear association has been shown with age. The syndrome occurs worldwide but its prevalence seems to vary from country to country. The best-known sign of exfoliation syndrome is deposits of greyish-white material on the anterior lens surface. Sometimes exfoliation material can also be seen at the pupillary border, on the anterior iris surface, corneal endothelium, and on the anterior vitreous face. When clinically detected, exfoliation syndrome is somewhat more often unilateral than bilateral. According to recent investigations clinically unilateral exfoliation syndrome is probably never truly unilateral but rather asymmetric, because exfoliation material has been detected ultrastructurally and immunohistochemically around iris blood vessels of the nonexfoliative fellow eyes. Indeed, electron microscopy identifies in various organs of patients with exfoliation syndrome fibrils similar to those seen in intraocular exfoliation deposits. Other clinical signs associated with exfoliation syndrome are pigment dispersion, transillumination defects of the iris and reduced response to mydriatics. In unilateral exfoliation syndrome, intraocular pressure (IOP) of the exfoliative eye is approximately 2 mmHg higher than IOP of the nonexfoliative fellow eye. Whether elevated IOP, vascular changes or exfoliation syndrome itself is the main factor causing optic nerve head damage and conversion of an exfoliative eye to glaucomatous, is not known. Glaucoma in the exfoliation syndrome has been shown to have a more serious clinical course than in primary open-angle glaucoma (POAG). At the time of diagnosis, IOP and its diurnal variation are generally higher and visual field defects tend to be greater in exfoliation glaucoma than in POAG. Because the decrease in lOP variation and lowering of the mean IOP level has been shown to improve visual field prognosis more in exfoliation glaucoma than in POAG, the glaucomatous process is considered to be more pressure-related in exfoliation glaucoma. Furthermore, progression of optic disc damage has been shown to be similar in exfoliation glaucoma and POAG when lOPs are lowered to a comparable level by the treatment. However, vascular disturbances in the posterior segment of the eye might after all be of equal importance in these two types of glaucoma; optic disc haemorrhages and venous occlusions have been reported to be as frequent in exfoliation glaucoma as in POAG. Perhaps in exfoliation glaucoma circullatory disturbances combined with high IOP lead to a particularly relentlessly progressing form of the disease.

Achromatic and short-wavelength automated perimetry in patients with glaucomatous large cups.

To evaluate visual function and optic disc features in patients with large cup-disc ratios (C/Ds). One eye of 86 patients with vertical C/Ds by contour of at least 0.8, who had undergone both standard achromatic automated perimetry (SAP) and short-wavelength automated perimetry (SWAP) testing, was selected retrospectively. Two masked glaucoma specialists independently graded stereoscopic photographs for vertical C/Ds, rim thinning, notching, excavation, optic disc hemorrhages, and nerve fiber layer defects. Visual fields were classified as abnormal if the glaucoma hemifield test result, corrected pattern standard deviation, or mean deviation was outside age-specific normal limits. Confocal scanning laser ophthalmoscopy was used to determine disc area. SAP and SWAP results were abnormal in 44 (51%) and 52 (60%) of 86 patients, respectively. In patients with normal SAP results, SWAP results were abnormal in 14 (33%) of 42 patients. In patients with normal SWAP results, SAP results were abnormal in 6 (18%) of 34 patients. Small discs are associated with an abnormal SAP result (P = .01) and an abnormal SWAP result (P = .09). An increased vertical C/D greater than the qualifying level of 0.8 was associated with an abnormal SAP or SWAP result (P< or =.001). Rim thinning (P = .01) and disc hemorrhages (P = .04) were associated with an abnormal SAP result. Many patients with large C/Ds have normal SAP and SWAP results. Compared with SAP, SWAP results were abnormal in a higher percentage of these patients. If a patient has a large C/D and normal SAP results, SWAP testing may detect functional loss earlier. If glaucoma is defined by both structural and functional loss, patients with large vertical C/Ds, normal SAP results, and abnormal SWAP results may have glaucoma. Longitudinal studies are needed to assess this hypothesis and determine whether these patients subsequently develop abnormal SAP results as well.

Glaucomatous Versus Nonglaucomatous Optic Disc Cupping: Clinical Differentiation

Cupping of the optic nerve head associated with normal intraocular pressure (IOP) is a common clinical presentation for which clearly defined management guidelines have not been established. The clinical approach represents a diagnostic challenge because the mechanism of optic nerve injury is often difficult to objectively establish. Of paramount importance is the primary distinction between physiologic cupping and pathologic cupping, and the accurate subclassification of eyes with pathologic cupping. Therefore, it is essential for clinicians to differentiate glaucomatous from nonglaucomatous disc damage. This article reviews the clinical differentiation of eyes with glaucomatous and nonglaucomatous optic disc cupping.An effective, albeit imperfect, rule of thumb dictates that eyes with retention of central acuity, absence of dyschromatopsia, and vertical cupping that corresponds to a nerve fiber bundle visual field defect are generally glaucomatous. Compressive lesions of the anterior visual pathway are an uncommon finding in the evaluation of glaucoma patients with visual field loss associated with normal levels of IOP. Clinically silent lesions, unassociated with visual pathway compression, may be found in less than 10% of patients.The most specific signs of glaucomatous cupping are splinter optic disc hemorrhages, family history of glaucoma, and nerve fiber bundle visual field defects. The most specific signs of nonglaucomatous cupping are age under 50 years, optic disc pallor in excess of cupping, and field defects that border the vertical meridian. Attention to these clinical variables may help provide high quality yet cost-effective health care to patients with visual field loss associated with optic nerve cupping at normal levels of IOP.

Correlation of the Peripapillary Atrophy Area with Optic Disc Cupping and Disc Hemorrhage

To investigate the association of the peripapillary atrophy area with disc cupping area and disc hemorrhage in subjects who underwent ocular examination as part of a routine physical examination. We reviewed plain color fundus photographs taken of 12,140 eyes of 6,070 subjects as part of a routine health examination. The refractive error in these eyes was not known. Using a computerized image analysis system, we measured the area of peripapillary atrophy (zone beta), the optic disc, and optic disc cupping by means of planimetry in 8,842 eyes of 4,421 subjects with fundus images of good quality. The ratio of cup area to disc area was significantly greater in eyes with peripapillary atrophy (0.36 + 0.09) than in eyes without peripapillary atrophy (0.34 + 0.07), and the ratio of peripapillary atrophy area to disc area was significantly greater in eyes with disc hemorrhage (0.26 + 0.34) than in those without disc hemorrhage (0.09 + 0.18). Moreover, in eyes with peripapillary atrophy, the ratio of cup area to disc area was significantly larger in eyes with disc hemorrhage (0.48 + 0.08) than in those without disc hemorrhage (0.36 + 0.09). These results remained statistically unchanged even after "glaucomatous" eyes were excluded from the study. Peripapillary atrophy appears to be associated with a higher degree of cupping of the optic disc and disc hemorrhage, and the results suggest an association between peripapillary atrophy and glaucomatous optic neuropathy.

The 5-year risk of MS after optic neuritis

Reply from the Authors: We appreciate the interest of Drs. Lee and Brazis in our study results. All 26 of the patients with severe optic disc edema, retinal or disk hemorrhage, or macular exudates had no brain MRI lesions, and, as noted by Drs. Lee and Brazis, none of them developed CDMS within 5 years of optic neuritis. Excluding these patients from the CDMS risk assessment increases the life-table estimate of the 5-year risk of CDMS from 30% to 32% in the full cohort and from 16% to 19% among patients with no brain MRI lesions at the time of optic neuritis. We concur with Drs. Lee and Brazis's suggestion that when any of these ophthalmoscopic features are associated with optic neuritis in the presence of normal brain MRI, the etiology of the optic neuritis almost always, if not always, has an etiology …

The cupped disc: Who needs neuroimaging?

Objective To determine the incidence of positive neuroradiologic studies in consecutive patients with glaucoma associated with normal intraocular pressure and to compare the psychophysical and clinical characteristics of these eyes with eyes with disc cupping associated with intracranial masses. Design Retrospective case-controlled study. Participants Fifty-two eyes of 29 patients with glaucoma associated with normal intraocular pressure and 44 eyes of 28 control patients with compressive lesions were reviewed. Intervention The medical records of consecutive glaucoma patients with normal intraocular pressure who underwent brain magnetic resonance imaging or computed tomography scanning as part of a diagnostic evaluation between January 1, 1985, and July 1, 1995, were reviewed. A masked reading of optic nerve photographs and visual fields was performed by one observer. A similar analysis was performed on a control group of consecutive patients with nonglaucomatous optic nerve cupping with known intracranial mass lesions. Main outcome measures The neuroradiologic findings, clinical characteristics, optic nerve head appearance, and patterns of visual field loss were compared between groups. Results None of the patients diagnosed with glaucoma had neuroradiologic evidence of a mass lesion involving the anterior visual pathway. Compared to control subjects, patients with glaucoma were older ( P = 0.0001), had better visual acuity ( P = 0.002), greater vertical loss of neuroretinal rim tissue ( P = 0.0001), more frequent optic disc hemorrhages ( P = 0.01), less neuroretinal rim pallor ( P = 0.0001), and more nerve fiber bundle visual field defects aligned at the horizontal midline ( P = 0.0001). Visual acuity less than 20/40, vertically aligned visual field defects, optic nerve pallor in excess of cupping, and age younger than 50 years were 77%, 81%, 90%, and 93% specific for nonglaucomatous cupping associated with compressive lesions, respectively. Conclusions Anterior visual pathway compression is an uncommon finding in the neuroradiologic evaluation of patients with a presumptive diagnosis of normal-tension glaucoma. Younger age, lower levels of visual acuity, vertically aligned visual field defects, and neuroretinal rim pallor may increase the likelihood of identifying an intracranial mass lesion.

Deterioration of visual fields in patients with glaucoma with and without optic disc hemorrhages

Deterioration of visual fields in patients with glaucoma with and without optic disc hemorrhages

Optic disc hemorrhages in a population with and without signs of glaucoma

This study aimed to determine the prevalence and associations of optic disc hemorrhage in a well-defined older Australian population. The study design was a population-based, cross-sectional study. A total of 3654 persons 49 years of age or older, representing 88% of permanent residents from an area west of Sydney, participated in the study. Participants underwent a detailed eye examination. The diagnosis of optic disc hemorrhage was made from masked photographic grading; disc hemorrhages were subclassified as flame or blot in shape. Open-angle glaucoma was diagnosed from matching visual field loss and optic disc rim thinning. The overall prevalence of disc hemorrhage in either or both eyes was 1.4%. Disc hemorrhage prevalence was higher in women (odds radios [OR], 1.9; confidence interval [CI], 1.0-3.5) and increased with age (OR, 2.2 per decade; CI, 1.7-2.8 per decade). The overall prevalence in subjects with open-angle glaucoma was 13.8% (8% in high-pressure glaucoma and 25% in low-pressure glaucoma) and 1.5% in subjects with ocular hypertension. Disc hemorrhages were associated with increasing intraocular pressure (OR, 1.7 per 5 mmHg; CI, 1.3-2.3 per 5 mmHg), pseudoexfoliation (OR, 3.5; CI, 1.1-11.8), diabetes (OR, 2.9; CI, 1.4-6.3), and increasing systolic blood pressure (OR, 1.1 per 10 mmHg; CI, 1.0-1.3) after adjusting for age and gender. Among subjects without open-angle glaucoma, disc hemorrhages were more frequent in eyes with larger vertical cup-disc ratios and in subjects with a history of typical migraine headache (OR, 2.2; CI, 1.1-4.6). No associations were found among subjects with a history of vascular events, smoking, regular aspirin use, or myopia. Disc hemorrhage prevalence in this population is higher than that in the two previous population-based reports. Although the strong association of disc hemorrhage with open-angle glaucoma was confirmed (particularly low-pressure glaucoma), most disc hemorrhages (70%) were found in participants without definite signs of glaucoma.

The Associations of Optic Disc Hemorrhage with Retinal Nerve Fiber Layer Defect and Peripapillary Atrophy in Normal-tension Glaucoma

Objective: The purpose of the study is to elucidate a topographic correlation between optic disc hemorrhages and retinal nerve fiber layer defects as well as peripapillary atrophy in normal-tension glaucoma (NTG).Design: The authors prospectively studied the relation between the precise locations of disc hemorrhages and retinal nerve fiber layer defects in the first part of the study. The authors also compared morphometrically the peripapillary atrophy and the optic disc in eyes with disc hemorrhage with eyes without a history of disc hemorrhage in agematched patients in the second part of the study.Participants: In part 1, 42 patients with NTG (male/female = 11/31; age, 56.8 ± 14.2 years) in whom new disc hemorrhages developed were enrolled. In part 2, 51 randomly selected age-matched patients with NTG without a history of disc hemorrhage (male/female = 16/35; age, 55.7 ± 12.5) were examined.Main Outcome Measure: In part 1, retinal nerve fiber layer defects were observed by scanning laser ophthalmoscopy using an argon-blue laser. In part 2, the area, angular extent, and radial extent of zone beta of peripapillary atrophy and the structural parameters of optic disc were measured by scanning laser tomography using a diode laser.Results: In part 1, the authors detected 64 disc hemorrhages in 48 eyes of 42 patients; retinal nerve fiber layer defects were shown in 47 (97.9%) of 48 eyes by scanning laser ophthalmoscopy. Of 64 disc hemorrhages, 51 (79.7%) coincided with retinal nerve fiber layer defects in location. These 51 hemorrhages were present on the border (41.2%) or adjacent to the border (58.8%) between the retinal nerve fiber layer defect and the apparently healthy-looking retinal nerve fiber layer. In part 2, the prevalence, area, angular extent of zone beta, and ratio of zone beta area to disc area were significantly greater in the disc hemorrhage group than in the nonhemorrhage group, even though there were no significant differences in disc parameters between the two groups.Conclusions: Disc hemorrhage is associated closely with retinal nerve fiber layer defect in location and the size of peripapillary atrophy in NTG.

Are there genuine and pseudo-normal pressure glaucomas? Body position-dependent intraocular pressure values in normal pressure glaucoma

Elevation of intraocular pressure in the supine position has been previously described in literature. Aim of this study is to investigate the elevation of intraocular pressure in normal tension glaucoma and its effect on the morphology of the optic disc, visual field function and capillary blood flow of the retina and optic disc. 56 eyes of 28 preperimetric and advanced normal tension glaucoma patients were prospectively evaluated. Ten eyes of ten normal patients served as a control group for the measurements of the intraocular pressure. In the course of a 24-h pressure profile applanation tonometry was performed in the morning in a supine and three and ten minutes later in a sitting position with Draeger's and Goldmann's tonometers. Arterial blood pressure was measured at the same time. The optic disc's morphology was evaluated by stereo photographs and Laser Scanning Tomography. As a sensory test computer perimetry was used. Capillary blood flow was measured at defined areas of the retina and optic disc. An intraocular pressure above 21 mm Hg in the supine position was used as a criterium to define two groups of normal tension glaucoma patients. In the supine position a statistically significant elevation of intraocular pressure was observed in 24 normal tension glaucoma patients by 6.2 +/- 2.8 mm Hg up to 21.8 +/- 3 mm Hg. Diastolic blood pressure in the supine position (80 +/- 10.5 mm Hg) was significantly lower than in the sitting position (94 +/- 11 mm Hg, p = 0.021). 12 of 28 normal tension glaucoma patients showed an intraocular pressure lower than 22 mm Hg in the supine position. In these patients a tendency towards a higher incidence for the occurrence of optic disc haemorrhages and significantly higher values for blood flow (p < 0.0005) and volume (p < 0.005) in the retina and optic nerve head could be shown. In this group of normal pressure glaucoma patients a higher incidence of migraine and vasospastic complaints was reported in the patients' history. In this study some normal tension glaucoma patients showed intraocular pressures in the supine position higher than 21 mm Hg and a lower diastolic arterial pressure. The higher incidence of haemorrhages and higher values for flow and volume parameters of the optic disc in normal tension glaucoma patients with an intraocular pressure lower than 22 mm Hg implicate the existence of two entities: real and pseudo normal tension glaucomas.