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Editors Selection IGR 9-4

Clinical Forms of Glaucoma: Rate of progression after disc hemorrhages

Comment by David Friedman on:

27199 The relationship between intraocular pressure reduction and rates of progressive visual field loss in eyes with optic disc hemorrhage, Medeiros FA; Alencar LM; Sample PA et al., Ophthalmology, 2010; 117: 2061-2066

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Disc hemorrhages are known to be a poor prognostic sign in primary open angle glaucoma and often are associated with subsequent worsening of the visual field. Medeiros et al. (1770) assessed the rate of progression of visual field loss after disc hemorrhage in the Diagnostic Innovations in Glaucoma Study (DIGS) cohort. Subjects were followed for over eight years on average, and rates of change in the visual field were assessed using the visual field index (VFI). Nearly 20% of subjects had a disc hemorrhage over study follow-up, and eyes having a disc hemorrhage had more than double the rate of visual field loss based on the VFI than those not experiencing one.

Eyes having a disc hemorrhage had more than double the rate of visual field loss

Furthermore, eyes with more than one disc hemorrhage over the follow-up period had even higher rates of visual field progression. Persons who developed disc hemorrhages had more severe glaucoma at baseline as measured by visual field indices and cup:disc ratio. Appropriate adjustment for these differences did not alter the findings of higher rates of progression with disc hemorrhage.

Reducing the IOP after a disc hemorrhage led to a slower rate of progression on average when assessing a subset of those in the DIGS cohort with at least four visual fields before and after a disc hemorrhage. However, some continued to worsen despite significant IOP lowering. Of particular interest, the mean rate of change after disc hemorrhage in eyes that had a 35% lowering of IOP was 0.13% per year, more or less no change or stabilization of the disease.

Eyes having a disc hemorrhage had more than double the rate of visual field loss

While this was not a randomized trial to assess how much IOP lowering is needed to halt visual field loss after disc hemorrhage, this finding offers a clinical guidepost for how to set a target IOP in patients experiencing disc hemorrhage. This must be used with caution, though, since some did not progress after disc hemorrhage, even when the IOP was not lowered very much. Therefore, while this paper supports attempting to lower IOP substantially after a disc hemorrhage is discovered in an eye with glaucoma, this clinical decision must weigh the benefits and potential harms of additional IOP lowering.

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