Images in the Medical Sciences| Volume 350, ISSUE 4, P329, October 2015

Splinter Hemorrhage: A Highly Specific and Poor Prognosis Sign for Glaucoma

      A 62-year-old woman presented for a routine eye examination. She had a positive family history for glaucoma. Her visual acuity was 20/20 in both eyes, and her pupils were reactive. Intraocular pressure was 22 mm Hg in the right and left eyes. Funduscopic examination of the left eye was normal; but a splinter hemorrhage was found in her right optic disc (Figure 1), and as a consequence, glaucoma was diagnosed. Campimetry was normal; therefore, metabolic control and a prostaglandin analog were started. Glaucoma is an important cause of preventable blindness, which is permanent if untreated; according to the World Health Organization, it is the second leading cause of blindness. Half of the patients with glaucoma are not diagnosed because of its asymptomatic and insidious onset. However, a complete ophthalmologic physical examination searching for the characteristic structural changes of the optic nerve head exceeds 90% for confirmation of the diagnosis of glaucoma. Classical features include enlargement or asymmetry of the cup, thinning of the neuroretinal rim or disc hemorrhages. Disc hemorrhages are a typical clinical sign; its presence alone is almost a guarantee of glaucoma. They are flame or splinter-like in shape, often with characteristic feathered ends. They have a radially and perpendicular orientation to the optic disc margin and extend from within the optic nerve head to the peripapillary retina. Reported rates for this type of hemorrhage range from 0% to 0.4% in normal patients, 2% to 37% in primary open angle glaucoma and 11% to 42% in normal tension glaucoma.
      • Uhler T.A.
      • Piltz-Seymour J.
      Optic disc hemorrhages in glaucoma and ocular hypertension: implications and recommendations.
      Unfortunately, disc hemorrhages are very difficult to spot during eye examination because of their subtle and self-limited condition; they may resolve in just a couple of weeks up to 2 months. Detection rates increase just by expending an extra time on fundoscopic examination and knowing that its presence is indicative of glaucoma with a poor prognostic factor that must be referred to an ophthalmologist for appropriate treatment.
      Figure thumbnail gr1
      Figure 1Normal left optic disc. Right optic disc with a splinter hemorrhage.
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        • Uhler T.A.
        • Piltz-Seymour J.
        Optic disc hemorrhages in glaucoma and ocular hypertension: implications and recommendations.
        Curr Opin Ophthalmol. 2008; 19: 89-94