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Editors Selection IGR 24-4

Prognostic factors: ONH hemorrhage size and visual field progression

Comment by Stephanie Noh & Steve Mansberger on:

117171 Clinical Significance of Optic Disc Hemorrhage Size in Visual Field Progression in Glaucoma, Jeong Y; Bak E; Bak E; Bak E; Bak E; Jang M et al., American Journal of Ophthalmology, 2024; 263: 109-116

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Disc hemorrhages (DHs) are strongly associated with the development and progression of glaucoma. While many studies report the association of glaucoma with the presence of disc hemorrhage, this study investigates the association between the size of the disc hemorrhage and risk for glaucomatous progression on visual fields. In this retrospective cohort study conducted at a tertiary center in South Korea, 250 patients with open-angle glaucoma with disc hemorrhages were followed for a minimum of five years. The main outcome measures were disc hemorrhage size and visual field progression, measured as the rate of mean deviation (MD) loss using guided progression analysis (GPA) on Humphrey visual field testing.

Subjects were divided into 'small' (< 0.049245 mm²) versus 'large' (> 0.049245 mm²) DH groups based on the median value. If there were multiple DHs, then the DH area was averaged. This study showed that the large DH group had statistically significant faster global MD loss rate and MD loss rate in the affected hemisphere (−0.51 ± 0.48 dB/y and −0.72 ± 0.66 dB/y, respectively), compared to the small DH group which loss rates of −0.36 ± 0.42 dB/y and −0.52 ± 0.59 dB/y (with p = .010 and .024, respectively). Notably, there was no difference in the rate of progression between the two groups in the unaffected hemisphere. Additionally, the authors looked at factors that influenced the rate of global MD loss and found that it was significantly influenced by larger mean DH area, larger maximum DH area and worse baseline MD using multivariate analysis (p-values < .05).

Overall, the study concludes that patients with large DHs should be examined more attentively given potentially faster VF progression. The strengths of this study include the large sample size and relatively long follow-up period. Practically speaking, it may be unfeasible for clinicians to ascertain the size of a DH based on the authors' measurement protocol in daily clinical practice. In this study, there was no significant difference in the reduction of IOP between the small and large DH groups, and there did not appear to be a significant percent IOP reduction after detection of DH (mean reduction of 4.0% ± 17.0%). In future studies, it would be interesting to see if greater IOP reduction especially in cases of large DH could potentially mitigate the rate of MD loss.

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