青光眼随诊时视盘出血的意义

青光眼随诊时采用系列眼底照相、计算机图像配比法是发现与追踪视盘出血（dischemorrhages,DH）及其相关改变的较好方法。观察DH对于青光眼病情随访、调整目标眼压及其他治疗方案具有重要意义。目前认为,DH是青光眼视网膜神经纤维层缺损加重及视野损害进展的重要危险因素,甚至认为是青光眼病情进展的先兆体征或标志。它可能是青光眼治疗不充分或未达到目标眼压的指征,对此应密切进行视神经形态与视野随访,并及时实施有效的降眼压治疗。（国际眼科纵览,2012,36：289—292）     

Positive predictive value of optic disc haemorrhages for open angle glaucoma

ObjectivesTo determine the positive predictive value (PPV) of disc haemorrhages (DHs) for the diagnosis of open angle glaucoma (OAG).MethodsA retrospective review of 618 consecutive new referrals by community optometrists to a hospital glaucoma service, including 54 patients with DHs. All patients had a comprehensive eye examination. The primary outcome was whether the patient was diagnosed with OAG in either eye, with a secondary outcome of whether they were discharged at the first visit (first visit discharge rate, FVDR).Results54 of 618 patients (8.7%) had a DH noted at the time of referral, including 21 referred with DH alone. 29 patients with DHs were diagnosed with OAG for a PPV of 54% (95% CI 40–67%), falling to 24% (95% CI 8–47%) in those with DH alone. The overall FVDR was 35%, increasing to 57% in those referred due to DH alone. The FVDR for those referred with DH alone was significantly higher than the FDVR of 25% among the 564 patients referred with suspected glaucoma without a DH (P = 0.001). The FVDR decreased to 35% for patients with a DH plus one other feature of glaucoma and to 0% for patients with a DH and at least two other features suggestive of glaucoma.ConclusionsAlmost 60% of patients referred due to isolated DHs were discharged at the first visit to the glaucoma clinic, however almost one in four was diagnosed with OAG. Patients with DH and other features suggestive of glaucoma had a higher probability of glaucoma diagnosis.Subject terms: Physical examination, Health care, Optic nerve diseases     

Clinical significance of hemorrhages in the optic disc

A consecutive series of 8029 first visit optometric examinations revealed 20 patients having hemorrhages of the optic disc. Assessment of optic disc contour, intraocular pressure (IOP), and visual fields was undertaken at detection of the hemorrhage and at follow-up not less than 3 months later. The disc hemorrhage patients were assessed for the presence of systemic occlusive disease. The sensitivity of disc hemorrhage as a sign of glaucoma was 0.3 in the sample. There was some risk of visual field loss after detection of a hemorrhage in eyes having glaucoma (1 of 6 eyes); a similar risk was observed in non-glaucomatous eyes in which bleeding occurred (4 of 14 eyes). Hemorrhages occurred in 8 eyes that remained clinically normal during the course of follow-up. Notching of the neural rim of the disc was common but overall changes in contour of the disc were observed in only one patient. An association between disc hemorrhage and systemic disease could not be established.     

Blood flow in retinal vessels of normal-tension glaucoma with or without a history of optic disc hemorrhages

PURPOSE: To evaluate blood flow in retinal vessels of normal-tension glaucoma (NTG) with or without a history of optic disc hemorrhages (DH) and compare it with that in non-glaucomatous eyes using scanning laser fluorescein video angiography. METHODS: We enrolled 14 eyes of 14 NTG patients with a history of DH (DH (+) group), 12 eyes of 12 NTG patients without history of DH (DH (-) group), and 10 eyes from 10 non-glaucomatous patients matched for age, intraocular pressure, and systemic blood pressure. No statistically significant difference was observed between the DH (+) and DH (-) groups of NTG in the global indices of the Humphrey visual field. Fluorescein angiography was performed using a scanning laser ophthalmoscope with an argon blue laser. A series of approximately 100 consecutive video images at 1/2 second intervals from just before the dye appearance in the central retinal artery was loaded into an external personal computer system. Based on this acquired image series, we obtained fluorescein filling curves for 10 x 10 pixel measuring areas placed on each of the superior-temporal and inferior-temporal branch retinal arteries and veins at 1/5 papillary diameter from the disc edge. In each vessel, time to the highest fluorescein intensity (peak time, sec) and the time constant of the filling curve (tau, sec) were obtained. Time difference between the peak times in vein and artery (peak time difference) was also calculated. RESULTS: Statistically significant differences were observed among the three groups in the peak time of inferior-temporal artery and vein, and superior-temporal vein (ANOVA, p < 0.01). Also there were statistically significant differences in the tau of all vessels (ANOVA, p < 0.05). No statistically significant differences were observed in the peak time differences. By multivariate analysis, the DH (+) and DH (-) groups of NTG showed significantly longer peak times and tau s than did the non-glaucomatous eyes (p < 0.05). However, no statistically significant differences were observed in any parameters between the DH (+) and DH (-) groups of NTG. CONCLUSIONS: In NTG, dye filling rate in both the central retinal arteries and veins seems to be delayed. However, this delay does not differ between DH (+) and DH (-) groups.     

Reproducibility of evaluation of optic disc change for glaucoma with stereo optic disc photographs

PURPOSE: To determine the reproducibility of the assessment for glaucomatous change in serial optic disc stereo-slides. DESIGN: Masked interobserver variability study. PARTICIPANTS: Serial optic disc stereo-slides from 40 patients. METHODS: Three independent ophthalmologists evaluated for change a set of two serial 20 degrees optic disc color stereo-slides of 40 patients. This test set was not from European Glaucoma Prevention Study (EGPS) patients. Each observer performed two evaluations at least 30 days apart and was masked from the temporal sequence of the slides and his or her previous evaluation. Each patient was graded as changed or stable by two-out-of-three agreement. A kappa statistic was used to calculate the intra- and interobserver reproducibility as well as the assignment reproducibility (first consensus versus second consensus). The same procedure was followed to test the reproducibility when another experienced ophthalmologist was added to one of the three reading centers. MAIN OUTCOME MEASURES: Reproducibility in evaluating glaucomatous optic disc change. RESULTS: The intraobserver reproducibility (95% confidence interval [CI]) in the evaluation of change ranged between 0.79 (0.45-1.14) and 1.00 (0.69-1.31). The interobserver reproducibility (95% CI) in the evaluation of change ranged between 0.45 (0.15-0.75) and 0.75 (0.44-1.06). The assignment reproducibility (first consensus versus second consensus in the evaluation of change) between the senior EGPS readers was 0.94 (0.63-1.25). The assignment reproducibility when another experienced ophthalmologist replaced one of the readers was 0.94 (0.63-1.25). CONCLUSIONS: The assignment reproducibility of three expert readers looking for glaucomatous change in serial optic disc stereo-slides was excellent. It remained so when one of the three experts was replaced by another experienced reader.     

Early optic disc changes in open-angle glaucoma

INTRODUCTION: Early diagnosis of chronic open-angle glaucoma is difficult: early changes in the optic disc often precede troubles in the field of vision, which occur gradually with no typical initial aspect. We report here the results of optic disc observations in normal subjects who became glaucomatous. OBSERVATIONS AND METHODS: A study was conducted on 64 eyes of 51 subjects followed on average over 12 years. At the start these eyes were normal or at risk for glaucoma for various reasons. Doubtful, difficult cases (severe myopia, dysversion or with associated pathology) were eliminated. Eventually, all the eyes presented open-angle glaucoma. All patients underwent clinical and paraclinical examinations by the same examiner. The optic discs of 78 dilated eyes were examined with a slit lamp and a 78-dioptre lens and the results systematically tabulated. Of the 78 optic discs, 40% had initial morphological characteristics (including cup/disc ratios) that were difficult to identify precisely. Preference was given to certain criteria that were easy to evaluate and likely to change. RESULTS: The classic aspects of glaucomatous papillary excavation appearance were observed. Forty-four discs showed notable changes (19 typical changes, 25 atypical), which were observed before visual field abnormalities. The size of the disc influences how the disease develops. Also noted were the frequency of changes in the slope of the papillary profile curve (third moment) and the frequency of changes in the quality of the papillary tissue, which takes on a translucent character locally. CONCLUSION: Documented and comparative observation of the optic disc remains a good and simple means for supervising subjects at risk for and in early diagnosis of chronic open-angle glaucoma. The evaluation of changes in the optic disc is greatly aided by the collection and the systematic recording of observations.     

Expert agreement in evaluating the optic disc for glaucoma.

The authors studied intraobserver and interobserver agreement, under monoscopic and stereoscopic conditions, in estimating vertical cup-to-disc ratios and in assessing whether a disc had glaucomatous damage. Six glaucoma experts evaluated 75 optic disc photographs under both viewing conditions. The experts also re-evaluated 25 photographs. Intraobserver agreement in estimating vertical cup-to disc ratios was high (median weighted kappa, 0.79). Interobserver agreement in estimating vertical cup-to-disc ratios was moderate (stereoscopic median weighted kappa, 0.67); individual experts differed by as much as 0.2 disc diameters (DD) monoscopically and 0.16 DD stereoscopically. The observers estimated larger vertical cup-to-disc ratios when evaluating the same discs under stereoscopic conditions than under monoscopic conditions. Intraobserver agreement in assessing glaucomatous disc damage was substantial (median kappa, 0.76). Interobserver agreement in assessing glaucomatous damage was moderate (stereoscopic median kappa, 0.50). This study confirms the ability of experts to reliably evaluate the optic disc within themselves and emphasizes the need for developing standardized methods for interobserver evaluation of the optic disc in glaucoma.     

Incidence of disc hemorrhages in open-angle glaucoma before and after trabeculectomy

PURPOSE: To investigate the effects of reduction of intraocular pressure (IOP) by surgical intervention on the frequency of disc hemorrhages in eyes with primary open-angle glaucoma (POAG) and normal-tension glaucoma (NTG). DESIGN: Retrospective study. METHODS: We studied 99 eyes of 99 patients with POAG and 50 eyes of 50 patients with NTG, who underwent trabeculectomy with adjunctive mitomycin C (MMC) and were followed regularly at 1 to 3-month intervals at the Glaucoma Service of Gifu University Hospital. We applied Kaplan-Meier life-table analysis for the detection of disc hemorrhages before and after trabeculectomy. RESULTS: Trabeculectomy significantly reduced IOP (in POAG: 19.6 +/- 4.4 down to 11.1 +/- 4.2 mm Hg; in NTG: 15.3 +/- 1.5 down to 11.3 +/- 4.5 mm Hg; mean +/- SD). Life-table analysis revealed that the final cumulative probability of detecting a disc hemorrhage after surgery in POAG was 5.5 +/- 2.2% (calculated probability +/- SE) and was significantly lower than that (33.4 +/- 7.8%) before surgery (P < 0.0001, log-rank test). Likewise, the final probability after surgery in NTG was 23.1 +/- 6.3% and was significantly lower than that (42.1 +/- 8.8%) before surgery (P = 0.0063, log-rank test). CONCLUSIONS: IOP reduction via surgical intervention significantly decreases the frequency of disc hemorrhages in open-angle glaucoma patients.     

先天性视盘小凹并发黄斑病变的形态学特征

目的研究先天性视盘小凹并发黄斑病变的形态学特征及其在病程发展和激光治疗后的变化情况。设计回顾性病例系列。研究对象12例先天性视盘小凹合并黄斑病变患者。方法对临床诊断为先天性视盘小凹的患者资料进行回顾性分析,依据彩色眼底照相、相干光断层扫描及荧光素眼底血管造影检查结果结合既往有关小凹发病机制的理论进行分析归纳。对其中4例进行沿小凹区域的视盘边缘光凝治疗,观察期6—30个月。主要指标视力及黄斑病变特征。结果12例患者均合并浆液性黄斑病变,其中2例为单纯神经上皮脱离,2例为单纯神经上皮层间劈裂,其余两者兼有。病变区与小凹之间存在明确关联关系,病变程度与病程及视力也相关。2例合并先天性脉络膜缺损。3例激光治疗有效。结论视网膜神经上皮层间劈裂和神经上皮脱离是先天性视盘小凹合并黄斑病变的重要形态学改变,正确认识其与病程发展的关系有助于加深对发病机制的认识。激光治疗对部分患者有效。（眼科,2009,18：233—236）     

Inter-eye differences in chronic open-angle glaucoma patients with unilateral disc hemorrhages

OBJECTIVE: Flame-shaped optic disc hemorrhages are a hallmark of glaucomatous optic neuropathy. The purpose of this study was to evaluate which parameters differ between companion eyes with and without an optic disc hemorrhage in patients with chronic open-angle glaucoma. DESIGN: Comparative (companion eye) observational case series. PATIENTS: The study included 99 white patients with bilateral chronic open-angle glaucoma and unilateral flame-shaped optic disc hemorrhages. METHODS: All patients underwent qualitative and morphometric evaluation of color stereo optic disc photographs. MAIN OUTCOME MEASURES: Size and shape of the optic disc, neuroretinal rim and parapapillary atrophy, diameter of the retinal vessels, intraocular pressure measurements, and both mean value and loss variance value of the visual field examination. RESULTS: In an intraindividual inter-eye comparison, the eyes with disc hemorrhages and the contralateral eyes without disc bleeding did not vary significantly (P > 0.20) in size and shape of the optic disc and neuroretinal rim, optic cup depth, size of alpha and beta zone of parapapillary atrophy, retinal vessel diameter, intraocular pressure measurements, refractive error, and perimetric indices. CONCLUSIONS: In bilateral chronic open-angle glaucoma, the development of unilateral optic disc hemorrhages does not depend on inter-eye differences in size and shape of the optic disc, neuroretinal rim and parapapillary atrophy, diameter of the retinal vessels, intraocular pressure measurements, or visual field loss.     

Glaucomatous optic disc hemorrhages on confocal scanning laser tomographic images

PURPOSE: To evaluate the detectability of glaucomatous optic disc hemorrhages by confocal scanning laser tomography. METHODS: The study included 73 eyes of 63 patients, who consecutively showed optic disc hemorrhages on 15 degrees color optic disc photographs taken at baseline or during follow-up examinations and for whom confocal scanning laser tomographic images were additionally available. Of the total number of 92 observed hemorrhages, 51 hemorrhages extended into the parapapillary region and 41 hemorrhages were restricted to the intrapapillary region. The scanning laser tomographic images were searched for the disc hemorrhages already seen on the conventional disc photographs. RESULTS: Using the reflectivity images, 29 (32%) hemorrhages were detected on the scanning laser tomographs. None of the hemorrhages restricted to the intrapapillary region could be seen on the scanning laser tomographs. By evaluating each of the 32 single images of the scanning laser tomographic image series, 44 (48%) of the hemorrhages were identified on at least one single image. The detectability of disc hemorrhages on the scanning laser tomographs depended significantly on their extension into the parapapillary region or their intrapapillary location. Detectability of disc bleedings was statistically independent of the disc quadrant where the hemorrhage was located, width of the bleeding, size of the optic disc, neuroretinal rim, parapapillary atrophy, and type of glaucoma. CONCLUSIONS: Confocal scanning laser tomography is not very suitable for detection or documentation of optic disc hemorrhages in patients with glaucoma.     

Changes in optic disc in ocular hypertension and glaucoma

Most ophthalmologists use subjective methods to evaluate the optic disc for abnormalities and changes that occur in ocular hypertension and glaucoma. We have developed new techniques that allow more accurate evaluation of the blood supply to the optic disc and of changes in disc cupping and pallor. To evaluate the blood supply we use the technique of fluorescein angiography of the optic disc. With this technique, we have found that fluorescein defects commonly appear in open-angle glaucoma and ocular hypertension and are more frequent and larger in glaucomatous and ocular hypertensive discs than in normal optic discs. Fluorescein angiography demonstrates distinct changes in the blood supply to the optic disc in the glaucomatous or ocular hypertensive eye. Cupping of the optic disc is measured by photogrammetry from stereophotographs, which provide three-dimensional measurements not only of the volume of the cup, but of the depth, the slopes of the walls of the optic cup, and the area of the surface opening. This technique also allows us to determine a volume profile of the cup: that is, its cross-sectional area from top to bottom. The volume profile characterizes the shape of the optic cup and shows distinct differences in shape between normal, ocular hypertensive and glaucomatous cups. Pallor is measured by computerized image analysis. This technique allows us to determine the percent area of pallor of the optic disc. These three techniques permit us not only to evaluate abnormalities, but to measure changes over time in the optic disc in ocular hypertension and glaucoma, thereby increasing our diagnostic capability and improving patient management.     

Optic disc hemorrhages in glaucoma and ocular hypertension: implications and recommendations

PURPOSE OF REVIEW: To describe the epidemiology of disc hemorrhages and underscore the importance of detecting these markers of potential glaucomatous damage and progression. RECENT FINDINGS: The Ocular Hypertension Treatment Study has confirmed that disc hemorrhages are an independent risk factor in the development of glaucoma. The risk of developing glaucoma was six times more likely in ocular hypertensive patients with disc hemorrhages compared with ocular hypertensive patients without disc hemorrhages. This study also highlighted the difficulty in detecting disc hemorrhages on clinical examination, noting that only 16% of disc hemorrhages detected on stereophotographs were identified on funduscopic examination. One study has demonstrated that surgical lowering of intraocular pressure decreased the occurrence of disc hemorrhages. SUMMARY: Although the mechanism for the development of disc hemorrhages remains vague, the recent literature describes the difficulty in detecting disc hemorrhages, the importance of identifying this negative prognostic indicator and the effectiveness of intraocular pressure lowering with trabeculectomy in decreasing the risk of future disc hemorrhages.