Is disc hemorrhage an indication for more aggressive treatment?

Using data from the Early Manifest Glaucoma Trial, researchers looked at 255 patients with newly detected glaucoma that were randomized to argon laser trabeculoplasty plus betaxolol or no initial treatment. Patients were followed every three months up to 11 years. Disc hemorrhages were identified in approximately 55 percent of patients, and were equally common between treated and control patients (51.2 percent versus 45.2 percent respectively based on ophthalmoscopy, and 50.4 percent and 44.4 percent based on photographs). The frequency of these hemorrhages did not differ over time (8.4 percent versus 8.5 percent, respectively). Researchers found that IOP-reducing treatment was unrelated to the presence or frequency of disc hemorrhage.

The clinical implications from the results of this study are important to consider and challenge some current presuppositions about clinical glaucoma assessment and treatment.  Currently, clinicians believe that lowering IOP in patients diagnosed with glaucoma likely decreases the incidence of disc hemorrhages. The logic behind this has been that because disc hemorrhages is an indication of glaucoma progression and lowering IOP decreases the chances of progression; decreased disc hemorrhage with adequate treatment would follow.

There have been many indications of "pressure independent" factors related to glaucoma progression; the presence of disc hemorrhages, especially in association with normal tension glaucoma, being one of them.  The implication clinically is that subsets of patients, even with more typical appearing POAG, require more aggressive than usual treatment or different types of initial treatment.  Further study differentiating these patients from others in a clinically meaningful manner is needed to optimize more rational individualized treatment.

Financial Disclosures
Dr. Reynolds has no financial interests to disclose.