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EW GLAUCOMA 58 July 2016 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer assess if the IOP is responding. He explained that in chronic glaucoma management, scrutinizing the optic nerve is a priority. "Because of new information about how disc hemor- rhages are associated with damage, many physicians these days will take a look at the fundus even through the undilated pupil, just to look for hemorrhages and to confirm that this 'sign' is not present." Spotting a disc hemorrhage Spotting an optic disc hemorrhage takes a careful eye, according to Jody Piltz-Seymour, MD, Valley Eye Professionals, Huntingdon Valley, Pennsylvania, and Wills Eye Hospital Glaucoma Service, Phila- delphia. She said that finding disc hemorrhages requires extra special attention. "Disc hemorrhages are usually missed if you just look at the disc casually. They can be subtle and mimic blood vessels. When I teach residents, I tell them to look at the disc as part of the regular assessment, and then stop and scru- tinize the disc specifically for disc hemorrhages. If you don't take that step, you are going to miss them. Certainly, the best way to find them is by taking optic disc photographs and studying them under high magnification. In fact, in the Ocular Hypertension Treatment Study, the vast majority of photographically chair of ophthalmology, UNC Chap- el Hill, Chapel Hill, North Carolina. "Studies have shown that focal visual field defects oftentimes pre- cede or follow the development of a disc hemorrhage at a location 180 degrees away from the disc hemor- rhage on the visual field, and appear within the next 6 to 8 months. The appearance of a disc hemorrhage is therefore not pathognomonic for glaucomatous worsening, but often accompanies disease progression and should be taken as a potential sign of glaucoma instability." Disc hemorrhage was first described in people with normal pressure glaucoma but has been observed in high and normal pres- sure patients alike. According to Dr. Budenz, there is a jump in the incidence of optic disc hemorrhage in ocular hypertensives that become diagnosed with manifest glaucoma. He explained, "Our work in the Ocu- lar Hypertension Treatment Study showed that the yearly incidence of new optic disc hemorrhages in ocu- lar hypertensives was 0.5%. Once a patient developed manifest primary open angle glaucoma, it rose to 2.5% per year." 1 Patient management Disc hemorrhages resolve by them- selves and require no treatment, Dr. Budenz said. However, once Experts reveal how a finding as small as an optic disc hemorrhage may be a big predictor of glaucoma progression O ptic disc hemorrhage is a common clinical feature of glaucoma, indicating active disease with likely progression and visual field loss. These small bleedings form notch-like lesions at the edge of the optic disc in the nerve fiber layer and often correlate with visual field loss. Their detection necessi- tates the utmost vigilance in pa- tients diagnosed with glaucoma and in those who are glaucoma suspects. EyeWorld spoke with 2 glaucoma specialists to gain a better under- standing of optic disc hemorrhage and its predictive value. Disc hemorrhage and progression "Disc hemorrhage generally indi- cates instability of glaucoma," said Donald Budenz, MD, professor and Optic disc hemorrhage: Don't miss the signal Optic disc hemorrhage at the outer rim of the optic disc at 12:00 consistent with glaucomatous process Source: Donald Budenz, MD Glaucoma fundamentals E yeWorld is pleased to present our second "Glaucoma Fundamentals" column. The purpose of this column is to provide practical and usable tips for managing glaucoma issues in your daily practice. In this month's column, we address the importance of recognizing and managing optic disc hemorrhages. When disc hemorrhages are seen in patients, a number of questions race through the oph- thalmologist's mind: "What exactly does this mean?" "How do I explain this to the patient without making them panic?" "What are the next diagnostic and therapeutic steps?" "Do I need to refer this patient to a specialist, and if so, how quickly?" To answer these questions, we sought the opinions of 2 world-renowned glaucoma specialists: Donald Budenz, MD, and Jody Piltz- Seymour, MD. We hope EyeWorld readers find this "Glaucoma fundamentals" helpful. We welcome your feedback and your ideas for future columns. Husam Ansari, MD, Glaucoma fundamentals editor spotted, the physician should con- sider keeping a more careful watch over the patient and fine-tuning the treatment regimen. "In the setting of a glaucoma suspect, one would monitor that patient more closely, and if the patient had other risk factors that put him or her at high risk for development of glaucoma, one could consider instituting treat- ment," Dr. Budenz said. He added, "In a patient with manifest glaucoma, either the pres- sure is not adequately controlled for much of the time during the day or the pressures are fluctuating and causing instability in the glaucoma. Physicians might want to escalate therapy in that case by adding a medication to the existent regimen or performing laser surgery trabecu- loplasty." The challenge is trying to get the pressure stable throughout the day. He said, "Even if the pressure seems adequately controlled in the office, one generally has to assume that the pressure is not as well-con- trolled 24 hours a day, particularly when patients are supine or while sleeping, which can cause pressures to rise." Once he has identified an optic disc hemorrhage for which treatment is indicated, Dr. Budenz escalates the treatment and sees patients roughly 1 month later to

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