Disc Hemorrhage Location Predicts Visual Field Loss in Glaucoma

Over a three-year period, researchers found that inferior and temporal disc hemorrhages were linked to faster central and superior VF decline. These findings suggest that monitoring DH location could play a critical role in identifying high-risk patients and guiding personalized glaucoma management. Photo: Michael Chaglasian, OD. Click image to enlarge. Among risk factors for glaucoma progression—including older age, lower blood pressure, thinner central corneal thickness and elevated intraocular pressure—disc hemorrhage (DH) is well-established. These anomalies are known to be spatially associated with structural glaucoma deterioration; however, few studies have investigated the relationship between hemorrhage location and functional deterioration. Routine fundus photography, paired with high-quality visual field (VF) examinations, is essential to determine the association between DH and visual function. A new study in Ophthalmology Glaucoma followed patients with primary open-angle glaucoma (POAG) over three years, demonstrating that the location of a disc hemorrhage was strongly associated with corresponding clustered VF progression.The multicenter cohort study based in Japan included 186 eyes from 109 patients, all of which underwent VF testing, IOP measurements, fundus photography, and OCT scans quarterly over a three-year period. The mean age of patients was 58.6. Hemorrhage locations were categorized into superior, inferior, temporal and nasal quadrants. The VF was subdivided into superior, inferior and central regions, with the central field further divided into superior central and inferior central zones. Researchers then analyzed the relationship between disc hemorrhage history at specific locations and progressive changes in clustered total deviation (TD).Disc hemorrhage occurred in a total of 61 eyes (32.8%). Superior, inferior, temporal and nasal findings were observed in 19, 31, 21 and two eyes, respectively. The study reported the following results:A faster superior TD slope was significantly associated with inferior DH (-0.33 dB/year faster), but not with superior or temporal ones. A faster inferior TD slope was significantly associated with worse inferior baseline total deviation value and marginally associated with superior disc hemorrhage (-0.30 dB/year faster), but not with inferior or temporal DH.A faster central TD slope was significantly associated with temporal disc hemorrhage (-0.68 dB/year faster) as well as inferior location (-0.35 dB/year faster), but not with superior DH. Detailed analysis revealed that an inferiorly located hemorrhage was significantly associated with the superior central TD slope, but not with the inferior central TD slope. Although DH recurrence was observed in 33 eyes, the number of events did not show an additive effect on corresponding clustered VF progression.“Our findings align with the hypothesis that DH occurs at active sites of glaucomatous damage, supporting its role as a biomarker for areas of accelerated progression,” the researchers wrote in their paper. “These results highlight the importance of monitoring DH location to identify patients at higher risk for VF deterioration.”As a plausible explanation for their findings related to inferior disc hemorrhage associated with central VF progression, the authors cite the concept of the “macular vulnerability zone,” proposed by Hood et. al. “Most retinal ganglion cells in the inferior macular region are thought to project to this zone,” they explain in their paper. “Another point to consider is that the DH location may vary depending on the definition of the vertical position of the optic disc,” they continued, noting that they believe “superior DH also should be considered as a risk factor for VF deterioration, especially inferior VF deterioration.”The timing of DH was not accounted for in this study, which is a limitation identified by the authors. “It was challenging to analyze VF progression separately before and after DH because more than half of the eyes with DH experienced recurrence during the three-year follow-up,” they wrote. Since the study focused on the spatial relationship of Dh rather than the temporal relationship, this was unlikely to have significantly affected results, they continued.The study population primarily consisted of patients with normal tension glaucoma (NTG) (79%), which is the most prevalent form of the condition in Japan. “Since DH is more common in NTG than in high-tension glaucoma (HTG) (20.5% vs. 4.0%), it remains uncertain whether our findings can be directly applied to HTG. Further studies are necessary to explore this aspect,” the authors stated.Despite these factors, the researchers recommend eyecare providers consider more intense glaucoma treatment and careful monitoring of VF progression when DH is detected in patients with POAG. Click here for the journal source.  Akagi T, Fukuchi T, Higashide T, et al.; for the SVF Prospector Study Group. Associations between clustered visual field progression and locations of disc hemorrhages in glaucoma: A three-year prospective study. Ophthalmol Glaucoma. April 23, 2025. [Epub ahead of print].