Drance Hemorrhage

During an 83-year-old woman's annual eye examination, peripapillary retinal hemorrhages were detected immediately adjacent to the optic nerve head inferotemporally in the left eye. Both eyes were pseudophakic. She had a history of glaucoma and was currently using levobunolol, 0.5% solution daily, in both eyes.

The patient's distance visual acuity was correctable to 20/20 in the right eye and 20/25 in the left eye. Intraocular pressures measured 19 mm Hg. There was cupping or excavation of the temporal optic nerve rim. This finding is best observed with an ophthalmic lens and slit lamp. Loss of the nerve fiber layer causes neuroretinal thinning and the resultant cupping or excavation.

Disc hemorrhages that lie within the peripapillary retinal nerve fiber layer are known as Drance hemorrhages. They occur more often in patients with normal-tension glaucoma; one prospective study reported an incidence of 43% in these patients.¹ Drance hemorrhages can also occur in patients with primary open-angle glaucoma (when intraocular pressure exceeds 21 mm Hg), especially if treatment is inadequate. In patients with glaucoma and Drance hemorrhages, there is an increased risk of cupping, worsening atrophy of the nerve fiber layer, and progressive visual field loss after one year.² A Drance hemorrhage indicates disease progression and therefore the need to start or to increase the dosage of medical therapy.

In this patient, the levobunolol was discontinued and latanoprost, 0.005% solution daily, was started. One month later, her intraocular pressures had decreased to 15 mm Hg in each eye.