Drance hemorrhages and quarterly optic disc evaluation

Not very long ago, a 55-year-old African-American female presented with complaints of redness in her right eye for one week’s duration with mild discomfort. Medical history was significant for arterial hypertension, which was reportedly controlled with an oral beta blocker. Her entering corrected visual acuities were 20/25 OD and 20/30 OS.

Pupil function was normal, and intraocular pressure (IOP) by means of rebound tonometry was 14 mm Hg in each eye at 11:15 a.m. Slit lamp examination showed moderate temporal injection of the right episclera.

Her corneas were clear and devoid of staining, and her anterior chambers were both deep and quiet with open angles by the von Herrick method. Undilated examination of the OD optic nerve was as shown in Figure 1.

I dilated her and took photos after coming across this finding. Her vitreous was attached in both eyes. The remainder of the examination was unremarkable.

I diagnosed this patient with sectoral or nodular episcleritis of the right eye and prescribed fluoromethalone ophthalmic suspension to be used in the right eye every two hours for two days and then four times a day until her follow-up visit, which was arranged for one week later.

I then explained to her that she had an incidental finding of a superficial hemorrhage overlying her right optic nerve and that this could be a risk factor for glaucoma. We agreed that I would get her right eye all healed up and then perform subsequent glaucoma testing.

She reported no family history of glaucoma and was somewhat skeptical of my conversation until I showed her the photo.

One of my first thoughts regarding this patient is the fact that, going down the list of differential diagnoses for the cause of a retinal hemorrhage, the possibilities are endless and range from a hard sneeze to uncontrolled hypertension, uncontrolled glaucoma, optic neuritis, or a vitreous detachment (and many other causes in between).

All other factors aside, I decided to go with strong glaucoma suspect in the case of this patient due to the presence of what I would describe as suspicious cupping (which is evident even in the two dimensions of Figure 1). 

Next: Drance hemorrhages and glaucoma

Drance hemorrhages and glaucoma

Optic nerve hemorrhages, or Drance hemorrhages, often have an association with progression of glaucoma (especially in the case of normal tension glaucoma). This patient’s IOPs tend to be on the lower side late in the morning, and I would not have been surprised with even lower readings a few hours later-IOP tend to be higher in the morning hours than in the afternoon for many patients.

One potential lurking variable would be the presence of an oral beta blocker on this patient’s medical history, which may be masking ocular hypertension.

Regardless, the fact of the matter is that this patient has a superficial optic nerve hemorrhage, and I am now obligated to explain it. So, a glaucoma workup is in order, and I think there is a very good chance I’ll end up finding hard evidence of glaucoma and subsequently treating this patient.

Drance hemorrhages likely occur more often than clinicians detect them. This is due in large part to the fact that they tend to be relatively short-lived, perhaps lasting for just a couple of weeks.

Of utmost importance is the fact that these superficial and short-lived hemorrhages may indicate progression of glaucoma, thus prompting the clinician to consider being more aggressive with therapy.

When a Drance hemorrhage is seen in the presence of glaucoma, the clinician should seriously question whether or not the patient is at his target pressure (keeping in mind that target pressure is, by definition, the pressure at which a patient’s glaucoma does not progress).

When I detect a Drance hemorrhage, and especially if the patient is not at his or her current target pressure, I tend to get another visual field and SD-OCT study sooner rather than later.

If I detect progression, and the patient is at his current target pressure, then I know that the target pressure must now be lowered (likely prompting the initiation of additive therapy).

Once I stabilize a glaucoma patient, I will typically see him quarterly. I do not perform dilated optic nerve head assessments at all of these visits. I simply take an undilated look with my 78 D pre-corneal lens and record “(+) DH” or “(-) DH” in order to note the presence or absence of a Drance hemorrhage.

It doesn’t take but a few seconds, and it gives me one extra tool to look for progression in the presence of such a complex and multifactorial disease.

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