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Editors Selection IGR 21-4

Clinical glaucoma: ODH

Comment by Anders Heijl on:

15170 Detection and prognostic significance of optic disc hemorrhages during the Ocular Hypertension Treatment Study, Budenz DL; Anderson DR; Feuer WJ et al., Ophthalmology, 2006; 113: 2137-2143

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They found optic disc haemorrhages in a total of 123 or 7.6% of studied patients

In this large and very interesting study, Budenz et al. (1106) analysed optic disc haemorrhages (ODH) in 1618 OHTS patients. They found ODHs in a total of 123 or 7.6% of studied patients. Only 16% of ODH patients had been diagnosed clinically and the other 84% were detected only after inspection of disc photographs. Risk indicators for ODH were much the same as risk indicators for development of glaucoma damage in OHTS, i.e., older age, thinner corneas, and a positive family history. Not surprisingly, the 'glaucoma markers' higher PSD and higher C/D ratios were also significantly associated with ODH. It is interesting to note that higher IOP was not associated with ODHs despite the great importance of IOP for development of glaucoma damage.

The risk for development of glaucoma was 6 times larger in ODH eyes than in eyes where no ODHs had been photographed. The increase of risk in ODH eyes was 3.7 even in a multivariate analysis, which shows the importance of really looking for ODH in patients with ocular hypertension and other glaucoma suspects.

It has often been said that an ODH is a sudden catastrophic event, which is often soon followed by the development of a notch and visual field deterioration. This is not true; even when repeated haemorrhages have been seen the disc and field can remain unchanged.¹ The present study from the large OHTS material really demonstrates this very clearly; 87% of ODH eyes had still not developed a POAG endpoint at the end of the observation period.

Reflecting on the fact that only 16% patients were detected on clinical examination (even with leading glaucomatologists participating in OHTS!), I cannot help thinking back on my days as a young scientists 25 years ago, when it was common to hear leading glaucoma researchers stating that ODHs were very rare or non-existing in their countries. Given how easy it is to miss ODHs, is not difficult to understand why it took such a very long time before ODHs were universally accepted as common signs of glaucoma. We don't see what we look at, but what we look for.

We must be humble and realize that the finding of an optic disc haemorrhage in a glaucoma suspect has clear clinical significance, but that not finding one does not mean much, because: either an ODH can have been overlooked on clinical examination; or, given their intermittent nature, ODHs can be present only between examination. Even knowing this, I am a little surprised at the low frequency of ODHs in the OHTS populations. Some studies have shown that a clear majority of glaucoma patients have ODHs,² which becomes clear in studies where all patients have been examined many times. Does the low frequency of ODHs mean that a large majority of OHTS patients will never develop glaucoma damage, even after very long follow-up?

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