Case Report

Atypical Intrapapillary Hemorrhage in a Patient with Glaucoma

10.4274/tjo.32656

  • Sirel Gür Güngör
  • Gülce Gökgöz Özisik
  • Ahmet Akman
  • Leyla Asena

Received Date: 01.02.2014 Accepted Date: 30.04.2014 Turk J Ophthalmol 2015;45(2):77-78

A 73-year-old man presented for routine follow-up. There were primary open-angle glaucoma, diabetes mellitus, and usage of acetylsalicylic acid in patient’s history. Dilated fundus examination demonstrated cup hemorrhage in the right eye. Because of the progression of the superotemporal retinal nerve fiber layer defect in the last seven months, we think that the disk hemorrhage could be associated with glaucoma. (Turk J Ophthalmol 2015; 45: 77-8)

Keywords: Intrapapillary hemorrhage, glaucoma, retinal nerve fiber layer

Introduction

Disc hemorrhage, a round or splinter hemorrhage present on the optic disc or in the peripapillary retina extending to the disc rim, has been described in people with glaucoma. The prevalence of disc hemorrhages is about 0.9% to 1.4% in the normal population and 1.9% to 13.8% in patients with glaucoma.1,2 Other conditions associated with disc hemorrhage include diabetes mellitus, anticoagulation use, advanced age, female gender, and recent posterior vitreous detachment.3,4

Here, we report a case of glaucoma with an atypical optic disc hemorrhage, which was observed in the optic disc cup.


Case Report

A 73-year-old male patient presented for routine follow-up with a history of diabetes mellitus, which had been well controlled with medication. He was also taking acetylsalicylic acid. He had bilateral primary open-angle glaucoma and had been using latanoprost and timolol maleate fix combination for nine years. There were no ocular symptoms and no preceding trauma. Best-corrected visual acuity was 20/20 in both eyes. Intraocular pressures were 16 mmHg in the right eye and 14 mmHg in the left eye. The central corneal thickness was 540 µm in the right eye and 552 µm in the left eye. Slit-lamp examination was normal. Dilated fundus examination demonstrated a cup-to-disc ratio of 0.7 with a narrow temporal and superior neuroretinal rim and cup hemorrhage but absence of signs of papillitis or retinal vascular abnormalities in the right eye, and a cup-to-disc ratio of 0.6 with narrow temporal neuroretinal rim in the left eye (Figure 1a, 1b). These findings were not mentioned in his previous documentation, however, the optic coherence tomography (OCT) that was taken at the time showed the progression of the superotemporal retinal nerve fiber layer (RNFL) defect clearly when compared with the previous OCT from 7 months earlier (Figure 2a, 2b). Fluorescein angiography showed no abnormalities related to diabetic retinopathy. The patient has been under our follow-up for 9 more months, and the disc hemorrhage still exists.


Discussion

The pathogenesis of disc hemorrhage remains unclear, although both mechanical and vascular theories have been proposed. Optic disc hemorrhage can be caused not only by ischemic microinfarction in the optic disc, but also by mechanical rupture of small blood vessels arising from structural changes at the level of the lamina cribrosa.5 Vasculopathy associated with systemic hypertension and diabetes can cause microinfarctions and ischemic changes in optic disc vessels, making these vessels vulnerable to mechanical rupture.6

In this study, we report a 73-year-old male patient who presented with optic disc hemorrhage. The interesting point of this case was that the hemorrhage occurred in the cup of the optic disc rather than a more common splinter type hemorrhage. There were primary open-angle glaucoma, diabetes mellitus, and usage of acetylsalicylic acid in patient’s history. We did not think that the disc hemorrhage was associated with diabetes mellitus because the fundus examination showed no findings related to diabetic retinopathy. The possible reason of the persistence of the hemorrhage in this patient might be related to his usage of acetyl salicylic acid. Because of the progression of the superotemporal RNLF defect in the last seven months, we think that the disk hemorrhage could be associated with glaucoma, rather than diabetes mellitus in this patient.

Conflict of interest: The authots reported no conflict of interest related to this article.


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