Figure 1. Drance haemorrhage on the inferior nasal aspect of an optic nerve with enlarged vertical cupping from glaucoma
Dr Leonid Skorin Jr
OD DO MS FAAO FAOCO
Mayo Clinic Health System, Minnesota USA
Pacific University College of Optometry, Oregon USA
Drance haemorrhages are linear haemorrhages oriented perpendicular to the optic disc margin and within the retinal nerve fibre layer.
Also commonly known as disc haemorrhages, Drance haemorrhages have become synonymous with glaucoma due to their high prevalence in this population and their association with glaucomatous progression. Despite this, they are not unique to glaucoma.
Disc haemorrhages became common knowledge in the ophthalmic community due to extensive studies and reports by ophthalmologist Stephen Drance. In his key lecture at the World Glaucoma Congress in 2013,1 Dr Drance reported that disc haemorrhages were first described in the Danish literature in 1889 but were largely ignored until his investigations beginning in the mid-1960s. Drance’s first paper on disc haemorrhages was rejected by an editor who wanted biopsy specimens to determine their origin. Another journal published the paper and Drance has since produced more than 300 contributions to the glaucoma literature.
Aetiology, prevalence and detection
The exact pathophysiology of Drance haemorrhages remains unknown despite extensive research. Two main hypotheses for their origins exist: mechanical and vascular.2,3 The mechanical hypothesis states that structural changes to the optic nerve put stress on the surrounding blood vessels and eventually cause bleeding. The vascular theory states that poor structural integrity of the blood vessels results in blood leakage and subsequent damage to the optic nerve fibres. Because these haemorrhages are seen in glaucomatous and non-glaucomatous eyes, multiple factors may contribute to their development.
Factors observed to have a possible association with Drance haemorrhage incidence include increased age, diabetes, large vertical cup-to-disc ratio, smoking, female sex, increased intraocular pressure, increased systolic blood pressure, pseudoexfoliation and aspirin use.2,4
The reported prevalence of Drance haemorrhages varies in the general population from 0.6 per cent to 1.4 per cent.4 Based on many studies, it is clear that the prevalence is greater in patients with ocular hypertension (OH) and all types of glaucoma.3 Some research supports the greatest prevalence of Drance haemorrhage in normal-tension glaucoma (NTG), with one study reporting an incidence of haemorrhages in up to 25 per cent of patients.4
Variability in the reported prevalence of Drance haemorrhages may be secondary to difficulty in detecting them. No current imaging technology has the capability of detecting disc haemorrhages and they are easily missed on fundus examination.5 The most consistent method of detecting these haemorrhages is with fundus photography.
The Ocular Hypertension Treatment Study (OHTS) reported that four times as many Drance haemorrhages were discovered with photography than on standard disc evaluations.6 It is suggested that to increase detection sensitivity, the practitioner should assess the temporal aspect of the disc closely, especially the inferior temporal sector where two-thirds of these haemorrhages occur.
Drance haemorrhages and glaucoma
Detection of Drance haemorrhages is paramount for effective glaucoma management as they can be a harbinger of glaucomatous progression. Numerous studies have shown that in patients with glaucoma and Drance haemorrhages, there is an increased risk of optic nerve cupping, atrophy of the nerve fibre layer and visual field loss progression.4,7,8
The link between disc haemorrhages and glaucoma progression has been documented to be strongest for NTG. Some studies, such as the one completed by Rasker and colleagues, also report an association between Drance haemorrhages and visual field progression in OH and primary open angle glaucoma (POAG).7,8 In addition, the OHTS study reported that the presence of disc haemorrhages significantly increased the risk of progression to POAG from OH over an eight-year period.6
Recurrent disc haemorrhages are reported in 60 to 70 per cent of patients. The haemorrhage reoccurs in the same optic disc quadrant as the original haemorrhage 75 per cent of the time. The Collaborative Normal Tension Glaucoma Study and others have reported greater progression in patients with higher frequency of Drance haemorrhages.3
It is well-documented that the observed location of a Drance haemorrhage often corresponds with areas of optic nerve notching and visual field progression. There is some dispute about whether the changes in the nerve fibres occur prior to or following the appearance of the haemorrhage.5 What is clear is that in glaucoma suspects or patients diagnosed with glaucoma, the presence of a Drance haemorrhage indicates disease progression and the need to initiate or increase medical therapy.
Despite the strong association of Drance haemorrhages with glaucoma, it is important to consider that a reported 70 per cent of these haemorrhages occur in non-glaucomatous eyes.4 Posterior vitreous detachments, small vascular insults from systemic diabetes mellitus or hypertension, optic disc drusen, ischaemic optic neuropathy, leukaemia, and branch or central retinal vein occlusions can all result in disc haemorrhages.2,3,5 Presence of a disc haemorrhage in a patient previously undiagnosed with glaucoma requires careful disc evaluation for signs of glaucoma and consideration of alternative causes to prevent unnecessary glaucoma treatment.
Extensive research is still required to determine how Drance haemorrhages occur, why they are more common in some types of glaucoma and how they are linked to progression. Taking regular fundus photographs of glaucoma patients can help detect Drance haemorrhages and direct treatment.
In glaucoma suspects or those being treated for any type of glaucoma, presence of a Drance haemorrhage should initiate a change in medical therapy. In addition, patients with recurrent Drance haemorrhages should be treated even more aggressively and followed closely for glaucomatous changes. When medical treatments are no longer effective, surgical intervention may be required. In patients not diagnosed with glaucoma, assess for glaucoma risk factors and other ocular causes. Consider that Drance haemorrhage presence in this population may be secondary to vascular disease.
Figure 2. Inferior nasal Drance haemorrhage demonstrating the subtle presentation that often results in poor detection on fundus examination
Figure 3. Drance haemorrhage on the inferior margin of an optic nerve in a patient with NTG
1. Live Reports from the World Glaucoma Congress, July 17-20, Vancouver. 2013 [Accessed 12 October 2015]. Available from: http://eyeworld.org/printarticle.php?id=6955.
2. Leung D, Chan N, Tham C, Lam D. Disc hemorrhage: what do we know? 2010 [Accessed 12 October 2015]. Available from: http://www.cohk.org.hk/download/V14N1-p5.pdf.
3. Van Tassel S, Salim S. Optic disc hemorrhage. eye wiki. 2015 [Accessed 12 October 2015]. Available from: http://eyewiki.aao.org/Optic_Disc_Haemorrhage.
4. Healey P, Mitchell P, Smith W, Wang J. Optic disc hemorrhages in a population with and without signs of glaucoma. Ophthalmology 1998; 105: 2: 216-223.
5. Liebmann J. Finding and responding to disc hemorrhages. Rev Ophthalmol. Reviewofophthalmology.com. 2010 [Accessed 12 October 2015]. Available from: http://www.reviewofophthalmology.com/content/d/glaucoma_management/i/1205/c/22723/.
6. Kass M. The Ocular Hypertension Treatment Study. Arch Ophthalmol 2002; 120: 6: 701.
7. Drance S, Fairclough M, Butler D, Kottler M. The importance of disc hemorrhage in the prognosis of chronic open angle glaucoma. Arch Ophthalmol 1977; 95: 2: 226-228.
8. Rasker M, van den Enden A, Hoyng P. Deterioration of visual fields in patients with glaucoma with and without optic disc hemorrhages. Arch Ophthalmol 1997; 115: 10: 1257.
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