Visual outcome following subretinal hemorrhage in Best disease

PURPOSE

To review cases of Best disease associated with subretinal hemorrhage to better understand their long-term visual prognosis.

SUBJECT AND METHODS

Patients were identified through the photographic file database at the University of Iowa. Seventy-eight files of patients with clinical evidence of Best disease were reviewed and 12 patients (14 eyes) were identified with subretinal hemorrhage. The visual acuity and clinical course were reviewed in all of these patients when possible. Three patients demonstrated subretinal hemorrhage on their last follow-up visit. Nine patients (11 eyes) were followed through to resolution of subretinal hemorrhage. Eight patients were screened on the VMD2 gene and all were found to have disease-causing sequence variations.

RESULTS

All patients noted visual loss at presentation with subretinal hemorrhage (median 20/100; range 20/30-20/400). The median final visual acuity in the 11 eyes with follow-up was 20/50 (20/16-20/400 range). Ten of 11 eyes demonstrated improvement of vision with 9/11 having a final visual acuity of 20/50 or better.

CONCLUSION

The natural history of patients with Best disease with subretinal hemorrhage and moderate visual loss is relatively good. The presence of subretinal hemorrhage in Best disease may be related to mild, incidental trauma.

Nd:YAG laser treatment for premacular subhyaloid haemorrhage

PURPOSE

Premacular subhyaloid haemorrhage produces sudden, profound visual loss which may be prolonged if untreated. Nd:YAG laser treatment can create a posterior hyaloidotomy enabling rapid diffusion of subhyaloid haemorrhage into the vitreous gel. This study was performed to assess the results of Nd:YAG laser hyaloidotomy and to compare the outcome with similar conservatively managed cases.

METHODS

Nd:YAG laser hyaloidotomy was performed in 6 patients with premacular subhyaloid haemorrhage. The aetiologies were Valsalva retinopathy, macroaneurysm, branch retinal vein occlusion, proliferative diabetic retinopathy (2 cases) and idiopathic. Four patients with premacular subhyaloid haemorrhage were managed conservatively. The aetiologies were Valsalva retinopathy (2 cases), macroaneurysm and proliferative diabetic retinopathy.

RESULTS

Nd:YAG laser hyaloidotomy achieved rapid resolution of subhyaloid haemorrhage in all treated patients. Visual acuity improved to 6/9 or better in 4 patients, but was limited by ischaemic diabetic retinopathy in 2 patients. No patient had evidence of damage to the retina or choroid from treatment. Among the conservatively managed cases, 3 patients had slow resolution of the subhyaloid haemorrhage over 3-6 months. One patient with diabetic retinopathy demonstrated little improvement at 18 months.

CONCLUSION

Nd:YAG laser hyaloidotomy is a safe and effective procedure. It achieves rapid resolution of premacular subhyaloid haemorrhage with restoration of visual function, preventing the need for vitreoretinal surgery.

Benign idiopathic haemorrhagic retinopathy

PURPOSE

To describe a new condition characterised by an unusual unilateral idiopathic haemorrhagic retinopathy.

METHODS

A review is presented of patient histories from 5 patients with acute-onset unilateral idiopathic haemorrhagic retinopathy, including results of ophthalmological, haematological and fluorescein angiographic examinations.

RESULTS

All patients had an extensive deep blot haemorrhagic retinopathy without significant vascular signs or abnormal optic discs. In 4 cases the haemorrhage was sufficiently severe to break through into the vitreous. Fluorescein angiography demonstrated normal arteriovenous flow, without capillary non-perfusion, vessel or disc leakage. Disc swelling, macular oedema and cotton wool spots were not seen at any stage in these patients. All patients recovered the visual acuity in the affected eye by 4 months. Systemic examination in all cases was unremarkable.

CONCLUSION

This distinct and rare form of retinopathy is important to define since it has a good prognosis without treatment.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

Optic nerve blood flow was lower in NPG eyes with optic disc hemorrhages than in the contralateral eye and in controls.

Relationship between the severity of retinopathy and progression to photocoagulation in patients with Type 2 diabetes mellitus in the UKPDS (UKPDS 52)

AIM

to establish the degree to which the severity of retinopathy determines the risk for the need for subsequent photocoagulation in those with newly diagnosed Type 2 diabetes mellitus.

METHODS

Of 5102 patients entered into the UK Prospective Diabetes Study (UKPDS), 3709 had good quality retinal photographs that could be graded at entry. They were followed until the end of the study or until lost to follow-up, or until they received photocoagulation. Retinopathy severity was categorized as no retinopathy, microaneurysms (MA) only in one eye, MA in both eyes or more severe retinopathy features. The risk of photocoagulation was assessed in relation to severity of retinopathy at baseline, 3 and 6 years.

RESULTS

Of the 3709 patients assessed at entry to the UKPDS, 2316 had no retinopathy. Of these 0.2% needed photocoagulation at 3 years, 1.1% at 6 years and 2.6% at 9 years. Those with MA in one eye only (n = 708) were similar, with 0%, 1.9% and 4.7% needing photocoagulation by 3, 6 and 9 years, respectively. Amongst those who had more retinopathy features at entry (n = 509), 15.3% required photocoagulation by 3 years, and 31.9% by 9 years. When those without retinopathy at 6 years (n = 1579) were examined 3 and 6 years later (9 and 12 years after diagnosis), 0.1% and 1.8% required photocoagulation. Those with more severe retinopathy (n = 775) needed earlier treatment, 6.6% after 3 years and 13.3% after 9 years. The commonest indication for laser therapy was maculopathy, but those with more severe retinopathy were more likely to be treated for proliferative retinopathy and to need both eyes treated.

CONCLUSION

Few type 2 diabetic patients without retinopathy progress to photocoagulation in the following 3-6 years, while patients with more severe retinopathy lesions need to be monitored closely.

High-altitude cerebral edema (HACE): the Denver/Front Range experience

High-altitude cerebral edema (HACE) is a potentially fatal metabolic encephalopathy associated with a time-dependent exposure to the hypobaric hypoxia of altitude. Symptoms commonly are headache, ataxia, and confusion progressing to stupor and coma. HACE is often preceded by symptoms of acute mountain sickness and coupled, in its severe form, with high-altitude pulmonary edema. Although HACE is mostly seen at altitudes above that of the Denver/Front Range visitor-skier locations, we report our observations over a 13-year period of skier-visitor HACE patients. It is believed that this is a form of vasogenic edema, and it is responsive to expeditious treatment with a successful outcome.

Incidence and rate of disappearance of retinal hemorrhage in newborns

OBJECTIVE

To determine the prevalance, associated biometric factors, and rate of disappearance of neonatal retinal hemorrhage.

DESIGN

Cross-sectional and natural history study.

METHODS

Healthy newborns (n = 149) at an urban hospital were examined using indirect ophthalmoscopy within 30 hours of birth. Newborns with retinal hemorrhage were reexamined biweekly until hemorrhage resolved.

MAIN OUTCOME MEASURES

Neonatal and maternal biometric factors, and incidence and rate of resolution of retinal hemorrhage.

RESULTS

Intraretinal hemorrhage was present in 34% of newborns and varied from a single dot hemorrhage in one eye to bilateral widespread hemorrhages, occasionally with white centers. The incidence of hemorrhage was higher for vacuum-assisted (75%) than for spontaneous vaginal deliveries (33%) and was least for infants delivered by cesarean section (7%). The mean maternal age was greater for infants with retinal hemorrhage. By 2 weeks after birth, retinal hemorrhage resolved in 86% of eyes, and at 4 weeks no intraretinal hemorrhage was detected, although a single subretinal hemorrhage persisted until 6 weeks after birth.

CONCLUSIONS

Intraretinal hemorrhages are common in the immediate postnatal period and resolve by 1 month of age. Retinal hemorrhage in infants older than 1 month should heighten suspicion that the hemorrhage is associated with factors other than birth.

High-altitude retinopathy and retinal vascular dysregulation

PURPOSE

(a) To show that high-altitude retinopathy (HAR) is common at high altitudes even in well-acclimatised climbers and that it should not be regarded as part of the spectrum of benign mountain sickness but rather as a clinical sign with a separate aetiology. (b) To test the hypothesis that HAR could be interpreted as a clinical expression of 'ocular vascular dysregulation'.

METHODS

Both eyes of the 8 mountaineers of the First Vienna Himalayan Expedition in May/June 1996 were examined 2 weeks before departure to and 2 weeks after descent from a high altitude. Retinal blood flow was measured in the right eyes of 7 climbers, using the Heidelberg Retina Flowmeter (HRF).

RESULTS

Two of the 8 climbers had bilateral retinal haemorrhage after the expedition. In 5 climbers chronic hypoxic exposure caused an increase in retinal blood flow between +18% and +96%, and in 2 climbers a decrease in retinal blood flow between -21% and -31%. The 2 climbers (climbers 1 and 2) with bilateral retinal haemorrhage showed a significant increase in HRF parameters.

CONCLUSIONS

HAR may be a clinical sign of mountaineers with a tendency towards ocular vascular dysregulation. The pronounced increase in all haemodynamic parameters in the 2 climbers with retinal haemorrhage combined with a dilated epipapillary network 2 weeks after the exposure reflects a retinal vessel configuration, as might be expected at high altitudes under acute hypoxic stress. An inadequate autoregulatory response of the retinal circulation under conditions of chronic hypoxia may play an important part in the pathogenesis of HAR.

Ocular decompression retinopathy after resolution of acute primary angle closure glaucoma

A patient presented with acute primary angle closure glaucoma with markedly elevated intraocular pressure. Two weeks after laser peripheral iridotomy and resolution of the acute attack, the patient was noted to have developed scattered retinal haemorrhages. The haemorrhages resolved over time with no visual sequelae. This is the first reported case of ocular decompression retinopathy after resolution of acute primary angle closure glaucoma.

Disk hemorrhage is a significantly negative prognostic factor in normal-tension glaucoma

PURPOSE

We investigated the relationship between disk hemorrhage in normal-tension glaucoma and the progression of visual field defects and, additionally, whether hemorrhage plays a role in the pathogenic process of the chronic disease.

METHODS

We retrospectively reviewed the charts of 70 patients with normal-tension glaucoma (mean follow-up, 5.6 years) who were not medicated for glaucoma, and we applied a regression analysis of survival data based on the Cox proportional hazards model. Several clinical factors were investigated to find a possible association with the progression of glaucomatous visual field defined by two different definitions: one by mean deviation change and the other by glaucoma change probability analysis.

RESULTS

Disk hemorrhage, corrected-pattern standard deviation, age, systolic blood pressure, and pulse rate had a significant influence on the visual field defect. The cumulative probability of progression of visual field loss was significantly greater for patients with disk hemorrhage than for patients without disk hemorrhage by either criterion for progression (P </=.0008, logrank test). All eyes that had at least two occurrences of disk hemorrhage showed progression, whereas only three of nine eyes showed progression in the nonrecurrent disk hemorrhage group by the glaucoma change probability analysis. The difference was statistically significant (P <.0001, Fisher's exact probability test). Furthermore, there was a significant relationship between the location of the disk hemorrhage and the area of the progression of visual field loss in 65.4% of progressive patients with disk hemorrhage.

CONCLUSIONS

Several clinical factors other than intraocular pressure are significantly associated with the progression of visual field loss during the natural course of normal-tension glaucoma. Among these, disk hemorrhage is a significantly negative prognostic factor in patients with normal-tension glaucoma and may be a sign of progressive damage of the retinal nerve fiber layer, leading to functional deterioration of the visual field.

Intraocular hemorrhages associated with endoscopic spinal surgery

PURPOSE

To report the occurrence of intraocular hemorrhages in association with endoscopic spinal surgery.

METHODS

Case report.

RESULTS

A 40-year-old patient noted severe visual loss in both eyes after epidural endoscopy, epidurography, and endoscopic adhesiolysis. Ophthalmic examination showed a best-corrected visual acuity of RE: 20/800, and LE: counting fingers, and extensive subhyaloid, retinal, and subretinal hemorrhages in both eyes. The hemorrhages resolved over a period of 8 weeks and the best-corrected visual acuity improved to 20/40 in both eyes after 4 months.

CONCLUSION

A syndrome of visual loss and intraocular hemorrhages after an endoscopic spinal procedure is studied.

Foveal haemorrhages in diabetic retinopathy. Clinical characteristics and visual outcome

BACKGROUND

Haemorrhages from retinal vessels is one of the major clinical characteristics of diabetic retinopathy. Vitreous haemorrhages from retinal neovascularizations may extend to the visual axis and disturb central vision, whereas asymptomatic intraretinal haemorrhages may develop from ruptures of smaller retinal vessels. On rare occasions, however, smaller intraretinal haemorrhages may develop in the fovea, and consequently lead to a reduction in central vision. The clinical characteristics and visual outcome of these lesions have not been described in detail.

METHODS

Clinical data of 4724 diabetic patients (31.4% with type 1 diabetes and 68.6% with type 2 or other diabetes types) examined in the screening clinic for diabetic retinopathy at the Department of Ophthalmology, Arhus University Hospital, 1993-1998 were reviewed. Patients who had had a previous foveal haemorrhage were subjected to a full ophthalmological reexamination.

RESULTS

Six eyes of six patients with type 1 diabetes had previously had a foveal haemorrhage. The lesion had resulted in a visual reduction of on the average 1.4 visual acuity steps (SD=0.5, range:1-2, n=5), and resolution of the lesion was accompanied by an increase in visual acuity of on the average 1.2 visual acuity steps (SD=0.4, range: 1-2, n=6). Four of the patients had progressed to proliferative diabetic retinopathy and had received pan-retinal photocoagulation.

CONCLUSIONS

Foveal haemorrhages in diabetic retinopathy are accompanied by a mild and transient reduction in central vision. The lesions predominate in patients with type 1 diabetes of long duration, and may indicate that retinopathy has developed into a moderate or severe stage.

Natural course of submacular hemorrhage

BACKGROUND

Age-related macular degeneration (ARMD) is the most prevalent cause of blindness in the elderly population. This study retrospectively evaluated the natural course of submacular hemorrhage related to ARMD.

METHODS

We reviewed the records of patients with submacular hemorrhage and foveal avascular zone involvement at the Veterans General Hospital-Taipei from 1981 to 1996. Data were collected from color fundus pictures, fluorescence angiographic films and visual acuity changes.

RESULTS

Data from a total of 86 eyes with age-related macular degeneration (ARMD) and 37 non-ARMD eyes were collected. Analysis of data from the ARMD group revealed 10.5% visual acuity improvement six months after presentation and a final mean acuity of 0.069. Analysis of data from the non-ARMD group revealed 29.7% visual acuity improvement and a final mean acuity of 0.388.

CONCLUSIONS

In this study, patients with submacular hemorrhage had spontaneous visual improvement even without surgery, especially those without subretinal neovascularization.

Partial retinal artery occlusion after coil embolization of an intracerebral aneurysm

Occlusion of the retinal artery is a rare complication after therapeutic embolization. We present a case of a partial retinal artery obstruction following coil embolization of an intracerebral aneurysm. To our knowledge, only six cases of acute occlusion of the choroidal and/or retinal arteries after therapeutic embolization have been reported so far. The case presented here, however, is the first in which platinum microcoils were the material used. In addition the retinal ischemia was reversible, visual acuity returning to normal and cutten-wool spot and retinal hemorrhages resolving spontaneously.

Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure

OBJECT

The syndrome of retinal or vitreous hemorrhage in association with subarachnoid hemorrhage (SAH) is known as Terson's syndrome. The authors' purpose was to determine whether intraocular hemorrhage occurs with similar incidence when caused by severe brain injury accompanied by acutely raised intracranial pressure (ICP).

METHODS

Prospective ophthalmological examination was performed in 22 consecutive patients with SAH or severe brain injury and elevated ICP. Thirteen patients were admitted for SAH (World Federation of Neurological Surgeons Grades II-IV) and nine for severe brain injury (Glasgow Coma Scale scores 3-10). Monitoring of ICP was performed at the time of admission via a ventricular catheter. Initial ICP exceeded 20 mm Hg in all patients. Indirect ophthalmoscopy without induced mydriasis was performed within the 1st week after the acute event. Retinal or vitreous hemorrhage was seen in six (46%) of 13 patients with SAH and in four (44%) of nine patients with severe brain injury. Ocular bleeding was found bilaterally in three patients with SAH and in one patient with severe brain injury (18%). Six of the 10 patients with Terson's syndrome died as a result of their acute event.

CONCLUSIONS

The present results indicate that Terson's syndrome may be related to acute elevation of ICP, independent of its causes, and may occur with similar incidence in patients with severe brain injury and those with SAH. Because recognition and treatment of Terson's syndrome may prevent visual impairment and associated secondary damage to the eye, increased awareness of this entity in all patients with acute raised intracranial hypertension is recommended.

Terson syndrome: CT evaluation in 12 patients

PURPOSE

Terson syndrome may be overlooked in the acute setting and often requires ophthalmologic intervention to prevent long-term visual loss. In this syndrome, vitreous or retinal hemorrhage results from an abrupt rise in intracranial pressure, leading to retinal venous hypertension and intraocular hemorrhage. Our objective was to determine whether imaging findings could be discovered that might facilitate an earlier diagnosis.

METHODS

Our inpatient medical record data base for 1991-1996 listed 11 patients with Terson syndrome. The medical records of these 11 patients were reviewed retrospectively and compared with their noncontrast head CT scans and with scans of 10 control subjects. One additional case was discovered prospectively, for a total of 12 patients. Three radiologists unaware of the patients' history evaluated CT scans of the orbits for evidence of intraocular hemorrhage.

RESULTS

CT findings in eight patients were suggestive of retinal hemorrhage manifested by a retinal crescent or nodule that was slightly hyperdense relative to the vitreous humor. There was a high degree of concordance between the retrospective and independent reviews.

CONCLUSION

Retinal nodularity and crescentic hyperdensities are evident on CT scans in the majority of patients with Terson syndrome. Although findings are subtle and not present in all cases, in the setting of subarachnoid hemorrhage they suggest retinal hemorrhage and warrant detailed fundoscopic evaluation.

Visual fields after removal of subretinal hemorrhages and neovascular membranes in age-related macular degeneration

BACKGROUND

Surgical removal of subretinal hemorrhaging and membranes in eyes with age-related macular degeneration is feasible from a technical point of view, but no advantage over the spontaneous course of the disease has been proven. Visual acuity usually does not improve much. A realistic aim of surgical intervention may be diminution of the central scotoma size, which has not been studied.

METHOD

In a prospective study visual fields were measured preoperatively and 6 weeks and 6 months postoperatively in eyes operated on for subretinal hemorrhages and membranes in exudative age-related macular degeneration. The OCTOPUS 1-2-3 program glx, which tests the visual field of 60 degrees diameter at 59 points, was used. Changes in the total size of areas with sensitivity loss of 10-20 dB (= relative scotoma) and > 20 dB (= absolute scotoma) were interpreted as surgical effect. Patients with postoperative retinal detachment or neovascular recurrence were excluded. 30 eyes of 29 patients were enrolled (mean age 75.3 years, 11 male, 18 female) and divided into 3 groups: 14 eyes with massive subretinal hemorrhage of diameters > 30 degrees; 12 eyes with hemorrhages of 10 degrees-30 degrees; 4 eyes with mere neovascular membranes < 10 degrees.

RESULTS

(1) The visible area of damage is diminished by surgery (P < 0.01). The reduction for lesions > 30 degrees is 80%; for lesions between 10 degrees and 30 degrees the improvement is 43%. For lesions < 10 degrees there is no significant change. (2) The absolute scotoma size diminishes in all three groups (P = 0.05). The reductions are 63%, 57% and 21%, respectively. (3) Areas of absolute scotoma do not regain full function but are converted to relative scotoma depth, at best. Therefore, in the > 30 degrees group an overall increase (P < 0.01) of the relative scotoma size is observed. (4) The mean sensitivity in the 60 degrees field enhances by 1.6 dB (average over 30 eyes, P = 0.04). (5) Mean preoperative visual acuities were 0.03, 0.12 and 0.17, respectively, with no significant change after surgery. The power of testing is sufficient (0.93) to reject an increase of acuity from 0.12 to 0.2 in group 2.

CONCLUSIONS

For hemorrhagic subretinal lesions of diameter > 10 degrees a relevant reduction of central scotoma size is achieved by surgery. The final benefit for the patients depends on the frequency of surgical complications and neovascular recurrence.

Long-term observation of infants with macular hemorrhage in the neonatal period

Ten infants with macular hemorrhage in the neonatal period were tested to assess visual acuity, stereopsis, and ocular position. Contrast sensitivity was examined in three of them. The duration of hemorrhages was 1 month in four patients, 1.5 months in one patient, 2 months in two patients, 3 months in one patient, 4 months in one patient (corrected gestational 3 months), and 5 months in one patient (corrected gestational 2.5 months). None of the patients developed deprivation amblyopia or visual loss due to abnormality of macula. The results suggest that there is essentially no risk of visual deprivation for 3 months after birth. If there is any poor visual acuity, abnormal ocular position, abnormal eye movement, or poor stereopsis in the infant with neonatal macular hemorrhage, we have to elucidate the cause of the symptoms.

Experimental studies with perfluoro-octane for hemostasis during vitreoretinal surgery

PURPOSE

To investigate the effect of perfluoro-octane on coagulation studies and on intraoperative hemostasis during vitreoretinal surgery in an animal model.

METHODS

In vitro study--comparison of coagulation profiles (bleeding time, whole blood clotting time, partial thromboplastin time, and one-stage prothrombin time) of blood taken from healthy volunteers with and without the addition of perfluoro-octane. In vivo study--comparison of times taken to achieve hemostasis in a rabbit model with large retinal arterial bleeding in vitrectomized and aphakic eyes with and without intraocular injection of perfluoro-octane.

RESULTS

In vitro study--perfluoro-octane had no significant effect on coagulation profiles. In vivo study--intraocular perfluoro-octane significantly reduced the time to achieve hemostasis (P < 0.01) at all infusion bottle heights in vitrectomized and aphakic rabbit eyes.

CONCLUSIONS

Perfluoro-octane may be used to control bleeding during vitreoretinal surgery. A direct effect on the clotting cascade could not be demonstrated.

Electroretinographic findings in infants with the shaken baby syndrome

PURPOSE

To determine if electroretinography is helpful in the work-up of children with the shaken baby syndrome.

METHODS

Six children with retinal hemorrhages and the shaken baby syndrome underwent electroretinography (ERG). The ERGs of these six children were compared with six age-matched controls using the sign-rank test.

RESULTS

Neither the implicit time nor the amplitude of the white scotopic ERG response was significantly different between these patients and age-matched controls. Although the amplitude of the blue scotopic and 30 Hz flicker responses were attenuated (p < 0.05), the implicit times were not significantly different from controls. Three of the patients had serial ERGs recorded. The b-wave implicit time and amplitude improved in two of these patients. The ERG was helpful in distinguishing between a CNS and a retinal cause of visual loss in one child.

CONCLUSIONS

The ERG can be helpful in assessing retinal function in children with the shaken baby syndrome who have persistent visual impairment. In most cases, the ERG is not helpful in the initial assessment of children with the shaken baby syndrome.

Pathophysiology and management of subretinal hemorrhage

Subretinal hemorrhage can arise from the retinal and/or choroidal circulation. Significant subretinal hemorrhage occurs in several conditions, but most commonly is associated with age-related macular degeneration, presumed ocular histoplasmosis, high myopia, retinal arterial macroaneurysm, and trauma. Released toxins, outer retinal shear forces, and a diffusion barrier created by subretinal hemorrhage all contribute to photoreceptor damage and visual loss. The use of tissue plasminogen activator and improvements in surgical instrumentation have facilitated surgical drainage and have made it a useful option in the management of selected cases. Mechanisms of subretinal hemorrhage formation, underlying etiologies, diagnostic evaluation, and the histopathology of damage are summarized. Published surgical series are reviewed and surgical advances are summarized. The value of surgically removing subretinal hemorrhages to improve visual outcome remains unestablished, because definitive studies have not been performed. Guidelines for selecting candidates for surgical intervention are proposed.

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

OBJECTIVE

To evaluate visual field deterioration in patients with glaucoma with and without optic disc hemorrhages (DHs).

DESIGN

A prospective study at quarterly base involving annual perimetry; mean follow-up of 9 years.

SETTING

Outpatient department, nonreferral basis.

PATIENTS

Sixty-eight patients with primary open-angle glaucoma, 34 with normal pressure glaucoma (NPG), and 125 with ocular hypertension.

RESULTS

Visual field deterioration occurred in 32%, 32%, and 6% of the patients without DHs who had NPG, primary open-angle glaucoma, or ocular hypertension, respectively, while visual field deterioration occurred in 80%, 89%, and 14% of patients with DH, respectively. Cox proportional hazards ratio(CHR) for deterioration in patients with vs patients without DHs was 5.4 for NPG (P<.01) and 3.6 for primary open-angle glaucoma (P<.01). In patients with NPG and DHs, ipsilateral eyes with DHs deteriorated in 58%, while contralateral eyes without DHs deteriorated in 11% (CHR, 8.9; P<.04). For primary open-angle glaucoma and ocular hypertension, progression did not differ between eyes with DHs and contralateral eyes without DHs. Mean (+/-SD) interval between DHs and ipsilateral visual field deterioration was 3.1+/-1.7 years. No difference in the proportion of eyes progressing after single or recurrent DHs was noted. The position of DHs was related to the site of the visual field loss in 44% of the eyes.

CONCLUSIONS

The presence of DHs increased the risk of visual field deterioration. Disc hemorrhages were indicative only of deterioration in ipsilateral eyes in patients with NPG.