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Editors Selection IGR 17-3

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Comment by Don Budenz on:

22358 Disc hemorrhages and treatment in the early manifest glaucoma trial, Bengtsson B; Leske MC; Yang Z et al., Ophthalmology, 2008; 115: 2044-2048

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It has been reported that glaucoma eyes, particularly normal-tension glaucoma eyes, show a high prevalence of disc hemorrhage and that disc hemorrhage is related to the progression of glaucoma. However, there are few reports of whether glaucoma treatment reduces the possibility of disc hemorrhage. In this EMGT study, the main intervention is whether glaucoma treatment contributes to reducing the possibility of disc hemorrhage. If this were so, the diagnosis of disc hemorrhage would be a good indicator of the appropriateness of glaucoma treatment. However, the fact that the authors did not find any significant changes in the frequency of disc hemorrhage even with glaucoma treatment is an indication that disc hemorrhage is not a good indicator of the appropriateness of glaucoma treatment.
The most important issue regarding disc hemorrhage is whether disc hemorrhage is a result of or a predisposition to the deterioration of glaucomatous optic neuropathy. If the former were true, proper glaucoma treatment would reduce the possibility of disc hemorrhage. If the latter were true, glaucoma treatment would not have any effect on the possibility of disc hemorrhage. The results of this study support the latter hypothesis. However, we cannot deny the possibility that the current study does not have sufficient data to fully support this conclusion, because there are studies showing the opposite results.

Is a disc hemorrhage a result of, or a predisposition to the deterioration of glaucomatous optic neuropathy?

This study also indicates that the disease progression in glaucoma eyes with disc hemorrhage is much more rapid than that in eyes without disc hemorrhage. This result is supported by many previous reports. It is clear that we must treat glaucoma eyes with disc hemorrhage much more carefully than those without disc hemorrhage.
This study also shows that not all glaucoma eyes have disc hemorrhage. There is a subpopulation of glaucoma eyes that are highly susceptible to disc hemorrhage. Taken together, these results indicate that some risk factors, in addition to IOP, may worsen glaucoma at least in a subpopulation of glaucoma eyes. This study reminds us that we need to clarify IOP-independent risk factors and to determine ways to treat these eyes in addition to IOP reduction.

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