Clinical manifestations of eyes with peripapillary hyper-reflective ovoid mass-like structure presenting with optic disc hemorrhage as the initial onset

Clinical manifestations of eyes with peripapillary hyper-reflective ovoid mass-like structure presenting with optic disc hemorrhage as the initial onset | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical manifestations of eyes with peripapillary hyper-reflective ovoid mass-like structure presenting with optic disc hemorrhage as the initial onset Fen Zhou, Jin Yao, Qin Jiang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7272012/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective To observe the clinical manifestations in eyes presenting with optic disc hemorrhage (DH) as the initial sign, which were found to have peripapillary hyperreflective ovoid mass-like structures (PHOMS). Methods A retrospective observational study. Ten eyes of 10 patients diagnosed with DH combined with PHOMS at the Eye Hospital of Nanjing Medical University between January 2021 and May 2025 were enrolled. There were 2 male and 8 female patients. PHOMS was bilateral in 9 patients and unilateral in 1 patient. The mean age was 24.6 ± 9.6 years (range: 12–42 years). All affected eyes underwent best-corrected visual acuity (BCVA) testing, intraocular pressure (IOP) measurement, color fundus photography, B-scan ultrasonography, optical coherence tomography (OCT), fundus autofluorescence (FAF), and fundus fluorescein angiography (FFA). Results All patients experienced an acute onset of visual symptoms. Symptoms were mild, predominantly manifesting as floaters and mild vision loss. All patients had myopia and tilted disc. Four eyes had high myopia, 4 eyes had moderate myopia and 2 eyes had mild myopia. PHOMS was detected in 10 patients presenting with DH, and PHOMS was also identified in the contralateral eye in 9 of these patients. Based on bleeding area, the hemorrhages were classified as: isolated DH (3 eyes, 30%), Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH) (3 eyes, 30%), and IHAPSH with vitreous hemorrhage (4 eyes, 40%). Hemorrhage within the disc and adjacent subretinal hemorrhage were located nasally in 7 eyes, superiorly in 2 eyes, and inferiorly in 1 eye. Hemorrhage spontaneously resolved within 14 to 128 days (mean, 75.8 ± 41.2), and there were no recurrent hemorrhages. Visual acuity recovered to 1.0 in all patients after observation. Conclusion DH combined with PHOMS predominantly affects one eye in female patients. It could be classified by hemorrhage severity as isolated DH, IHAPSH, or IHAPSH combined with vitreous hemorrhage. The hemorrhagic phenomena resolved spontaneously without any specific treatment, and visual acuity recovered well. PHOMS DH IHAPSH Vitreous hemorrhage Clinical characteristics Multimodal imaging features Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Peripapillary hyperreflective ovoid mass-like structure (PHOMS) has received much attention in recent years. It is a special structure discovered in high-definition enhanced depth imaging optical coherence tomography (EDI-OCT) scans of the optic disc. Currently, it is believed that it is not a unique manifestation of a single disease and can appear in various diseases. The pathological mechanism of its formation may be related to the accumulation of axonal flow in the optic nerve fibers, which leads to the protrusion of nerve fiber axons around the optic disc (1). Previous studies have considered PHOMS as optic disc drusen (ODD), and indeed PHOMS and ODD are easily confused in ophthalmic imaging. The color fundus image of PHOMS has characteristic changes, manifested as blurred optic disc edges and a "C" - shaped halo. OCT shows a homogeneous mass structure outside the optic disc, above the Bruch membrane open (BMO), oval shaped, and similar to the reflex of the retinal nerve fiber layer. Typical PHOMS is oval shaped and located above the Bruch membrane adjacent to the optic disc (2-4). Myopia and optic disc tilt syndrome are more common in children with PHOMS, and are positively correlated with myopic refractive error and optic disc tilt (5). The special structure of tilted myopic disc in PHOMS might draw the retinal and choroidal tissues over and around the elevated edge, which influences blood supply of the optic disc. Therefore, this may lead to bleeding in patients with a tilted myopic disc, which may be spontaneous or triggered by an acute event (6). Currently, the cause of optic disc hemorrhage in PHOMS is not clear. Vascular obstruction, Bruch membrane rupture, and traction of the vitreous papilla were been proposed as possible causes (7). Optic disc and peripapillary retinal hemorrhage is a condition characterized by hemorrhages within the optic disc and surrounding retinal layers. The cause of this condition is uncertain . This may result from various factors, such as the anatomical structure of the optic disc, local vascular pressure changes, acting independently or in combination (8). Spontaneous hemorrhage of optic disc in PHOMS is a relatively rare syndrome. In some cases, bleeding within the optic disc extends into the peripapillary subretinal space or vitreous (9-10). The purpose of this study was to report on the findings of clinical features and multi-mode imaging features of PHOMS eyes with DH, which may help to identify the cause of DH. As far as I know, this is the first article in multiple sample cases to discuss DH secondary to PHOMS. Materials and Methods Study Design and Patients Ten consecutive patients with DH were identified and evaluated from July 2021 to June 2025 in Nanjing Medical University Affiliated Eye Hospital. Patients without PHOMS were also excluded. We also excluded patients with glaucoma, optic disc edema, optic neuritis, papillitis, ischemic optic neuropathy, optic nerve head drusen, or juxtapapillary neovascular membrane. All patients were followed up until the bleeding was completely resolved. The research adhered to the tenets of the Declaration of Helsinki. The institutional review board of the Nanjing Medical University Affiliated Eye Hospital approved the study. Informed consent was obtained from all participants. Medical and ocular history, ocular examination, and ancillary tests were performed for each patient. All patients underwent ophthalmic examinations performed by skilled technicians, including slit-lamp microscopy, IOP measurement, BCVA assessment, fundus color photography using a Topcon (Japan) fundus camera, optic nerve head OCT imaging (utilizing the single line scan mode) performed with Heidelberg Spectralis HRA OCT (Heidelberg Engineering, Germany), FFA and FAF imaging using Heidelberg confocal scanning laser ophthalmoscopy (CSLO) system (Heidelberg Engineering, Germany), and B-scan ultrasonography using a Tianjin Meda ODM-2100S ophthalmic A/B ultrasound scanner. The results were independently analyzed and interpreted by two retinal specialists. All patients took He Xue Ming Mu tablets to relieve hemorrhage. No other special treatments were given to the patients. They were closely observed throughout the follow-up period. Irregular follow-up was performed until the hemorrhage had completely resolved. Results In our study, 10 affected eyes of 10 patients were included. Clinical features were summarized in Table 1 . Patient age ranged from 12 to 42 years (mean, 24.6 ± 9.6 years). There were 8 females (80%) and 2 males (20%). All patients had an acute onset of visual symptoms at presentation, including floaters with or without mild blurred vision. Four patients experienced mild vision impairment, while the vision of 6 patients was 1.0. All patients had no systemic diseases, no vasculitis or trauma history. The intraocular pressure was within normal limits. The anterior segments were normal. Moreover, the patients did not experience any Valsalva manoeuvre. None of patients showed disc drusen; abnormal intraretinal, intrapapillary, or choroidal vasculature; or subretinal neovascularization after hemorrhage absorption. All patients had myopia and tilted disc. Four eyes had high myopia (spherical equivalent ≥ 6.0 diopters), 4 eyes had moderate myopia (spherical equivalents of 3.0–6.0 diopters) and 2 eyes had mild myopia (spherical equivalents of 0.25–2.75 diopters). Nine patients had bilateral PHOMS presentation and one patient had unilateral involvement. PHOMS can be observed on all affected eyes (Fig. 1 A, C). Nine patients had PHOMS presentation in contralateral eyes (Fig. 1 B, D). According to the dilated fundus evaluation, we classified the fundus performance into 3 groups: isolated DH (3 eyes, 30%) (Fig. 2 A-B), IHAPSH (3 eyes, 30%) (Fig. 2 C-D), and IHAPSH with vitreous hemorrhage (4 eyes, 40%) (Fig. 2 E-F). Hemorrhage within the disc and adjacent subretinal hemorrhage were located nasally in 7 eyes, superiorly in 2 eyes, and inferiorly in 1 eye. Fluorescein angiography was performed in 10 eyes. FFA showed blocked hypofluorescence due to peripapillary subretinal hemorrhage (Fig. 3 A). Vitreous bleeding located around the optic disc and in the inferior vitreous cavity in 4 patients. Five eyes had mild disc staining fluorescence in late stage. It was diffcult to assess disc staining because of a large area of blockage from extensive superficial and peripapillary subretinal hemorrhage in 5 eyes. Fundus autofluorescence showed that the optic disc and its surrounding area were obscured by hemorrhage, and no abnormal fluorescence was observed (Fig. 3 B). B-scan ultrasonography showed bulged optic disc (Fig. 3 C). In 2 patients, hemorrhage obscured optic disc on OCT image (Fig. 3 D). However, elevated optic disc could be vaguely seen. OCT demonstrated the nasal optic disc protrusion and subretinal hemorrhage was seen. After complete hemorrhage absorption, the structure of the optic disc could be clearly observed (Fig. 3 E-F). All patients had a good prognosis without any special treatments. The vision of 6 patients remained unchanged, while that of 4 patients improved to 1.0. The symptoms in all cases relieved in 2 weeks which may be due to the absorption of vitreous hemorrhage. The absorption of bleeding varied depending on the type of bleeding. The durations of hemorrhage absorption in DH, IHAPSH, and IHAPSH with vitreous hemorrhage were 21.3 days, 81.7 days, and 112.3 days, respectively. The mean hemorrhage resolved at 75.8 days after initial presentation. Regardless of the location, the hemorrhage in all cases faded. There have been no recurrences of intrapapillary hemorrhage in the same eye during the follow-up period (Fig. 4 A-C). Table 1 Demographic Characteristics and Clinical Findings of the Patients Case Affected eye Myopia (Diopters) PHOMS BCVA baseline Absorption time (day) Hemorrhage Location Optic disc hemorrhage peripapillary hemorrhage Vitreous hemorrhage 1 R −6.5 R&L 1.0 90 + + 2 R −7.5 R&L 1.0 85 + + 3 L −4.5 R&L 0.6 14 + 4 L −3.0 R&L 0.8 70 + + 5 R -8.0 R&L 1.0 20 + 6 L -1.5 R&L 1.0 120 + + + 7 R −5.0 R 0.8 106 + + + 8 R −6.0 R&L 0.8 30 + 9 R −2.0 R&L 1.0 128 + + + 10 L −3.0 R&L 1.0 95 + + + Discussion To our knowledge, this was the first study to describe the characteristics of PHOMS-related DH. DH was found both in glaucoma and posterior vitreous detachment (PVD). PVD-related optic disc hemorrhage presented in three types：flame, splinter, and dot or blot shape. Flame-shaped DH was majorly observed in the PVD group (11-12). In contrast, glaucomatous DH was commonly splinter-shaped. To date, a few of studies have reported optic disc hemorrhage associated with structural abnormalities of the optic disc, such as a small disc, tilted disc, or optic disc drusen (13-14). Due to the oblique insertion of the nerve into the sclera of the posterior staphyloma, the discs in myopic eyes appear tilted. This tilting results in elevation of the superior and nasal margin of the disc. Dragging of the retinal and choroidal tissues over and around the elevated edge put capillaries at risk for bleeding (20). IHAPSH was a common optic disc hemorrhage in patients with optic disc shape abnormalities (15). IHAPSH was also observed in patient with PVD (16-17). Takemoto et al. reported that 5 patients diagnosed with IHAPSH and OCT revealed PHOMS in all cases (14). In previous study, the fundus features of the tilted optic disc eyes showed peripapillary subretinal hemorrhage (PSH) alone, IHAPSH, and IHAPSH with vitreous hemorrhage (18). Based on the bleeding area in our series, the hemorrhages were classified as: isolated DH (30%), IHAPSH (30%), and IHAPSH with vitreous hemorrhage (40% ). We did not find the type of optic disc hemorrhage, such as PSH alone. However, in our case series, vitreous hemorrhage was present in 40% of the patients. All the bleeding patients were spontaneous. Moreover, hemorrhage could occur at any location on the optic disc except temporal side of the optic disc. It was speculated that the location of the bleeding is related to the degree of optic disc bulge which is more obvious on the nasal side. IHAPSH most commonly occured in Asian patients, especially in high myopia eyes (19). Our study showed that intrapapillary hemorrhage occurs most commonly in young healthy patients ranging from teenagers to adults with an average age of 24.6 years. This case series demonstrated a female predominance of 80%. Kokame et al. reported that the patients are often female (78%) (8). In previous study, 68% of eyes were in female patients and the mean patient age was 20 years (18). This is consistent with two reports. Our research indicated all patients had myopia. Four eyes had high myopia (spherical equivalent ≥ 6.0 diopters), 4 eyes had moderate myopia (spherical equivalents of 3.0–6.0 diopters) and 2 eyes had mild myopia (spherical equivalents of 0.25–2.75 diopters). The onset was sudden and unilateral, but symptoms were mild, predominantly manifesting as floaters and mild vision loss. There was no anterior segment or vitreous inflammation. The fundus showed a small, crowded optic disc with a small cup or no cup, and disc tilting. The disc margin might be slightly elevated and blurred nasally. Mild cases present with optic disc bleeding on the disc surface, while severe cases might present with IHAPSH. A well-demarcated, dark red, crescent-shaped subretinal hemorrhage was visible superior-nasal to the disc, encircling one-third to two-thirds of the disc rim. Hemorrhage could also be observed in the vitreous cavity. B-scan ultrasonography showed mild optic disc elevation without the calcified shadow characteristic of optic disc drusen. A minority of patients exhibit vitreoretinal adhesion or traction. OCT demonstrated optic disc elevation with hemorrhagic neurosensory detachment. FFA revealed that both the disc surface hemorrhages and the subretinal hemorrhage block fluorescence. The course and filling of retinal vessels were normal. In the late phase, the elevated disc might show slight fluorescein staining. Additionally, there was no autofluorescence or other abnormal fluorescence. When vitreous hemorrhage was merged, it might manifest as a boundary-blurred fluorescence blockage anterior to the retina. In the late phase of angiography, fluorescein staining was observed in the central portion of the optic disc without significant fluorescein leakage. This disease was a self-limiting condition. Hemorrhages spontaneously resolved without any particular treatment and complications with preserved visual acuity and optic nerve function. Kokame et al. reported that IHAPSH has a good prognosis with no sequelaes. Hemorrhage spontaneously resolved within 1–7 months (mean, 2 months) (8). Zeng R et al. reported that hemorrhage resolved at 2 months after initial clinical symptoms (9). Zou M et al. reported that the mean durations of hemorrhage absorption in IHAPSH was 2.53 months (18). In our case, the hemorrhage resolved at 75.8 days after initial presentation and the visual acuity completely recovered. Moreover, previous studies have shown that visual acuity maintained or improved in most cases and subretinal hemorrhage resolves spontaneously without sequelae in IHAPSH patients (8-9, 18,20). Therefore, after definitive diagnosis, observation with monitoring for hemorrhage resolution was appropriate to avoid unnecessary interventions. However, optic disc hemorrhage required differentiation from other diseases. A previous study investigated optic disc hemorrhage following the COVID-19 vaccination (21). They reported that an 18-year-old Japanese female developed optic disc hemorrhage after vaccination. Scott JA et al. had reported DH occurred after pupillary dilation (22). Moreover, valsalva maneuvers were another possible cause that may predispose patients to bleeding from the optic discs. This condition presented with a "boat-shaped" preretinal hemorrhage. Massive hemorrhage might extend into the vitreous cavity to obscure vision. This study is the first to analyze the clinical characteristics of a series of patients with DH combined PHOMS, and the patients included in the study have a large age range. At the same time, by observing the imaging features of different examination methods and combining multimodal imaging results, they can not only play to their own characteristics, but also complement each other's shortcomings, better helping clinicians to differentiate and diagnose PHOMS. However, this study also has shortcomings: the sample size is small, the time span for collecting patients is large, and this study is a retrospective study. In conclusion, correct diagnosis is particularly important to avoid unnecessary clinical mistherapy and anxiety in patients with DH combined PHOMS. Conclusions To provide patients with the most appropriate care and treatment, this report will help clinicians identifying the causes of optic disc hemorrhage and avoid unnecessary and invasive examinations and treatment. Abbreviations DH Optic disc hemorrhage PHOMS Peripapillary hyperreflective ovoid mass-like structures BCVA Best-corrected visual acuity IOP Intraocular pressure OCT Optical coherence tomography FAF Fundus autofluorescence FFA Fundus fluorescein angiography IHAPS Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage EDI-OCT Enhanced depth imaging optical coherence tomography ODD Optic disc drusen BMO Bruch membrane open PVD Posterior vitreous detachment Declarations Data availability statement The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author. Ethics statement The studies involving human participants were reviewed and approved by institutional review board of the Nanjing Medical University Affiliated Eye Hospital. Written informed consent to participate in this study was provided by the participants’ legal guardian. Conflict on interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Author contributions FZ collected the data and wrote the first draft of the manuscript. QJ and JY reviewed and revised the manuscript and produced the final version. All authors read and approved the final manuscript. Funding This research was funded by the National Natural Science Foundation (grant number 82070983) References Malmqvist L, Sibony PA, Fraser CL, Wegener M, Heegaard S, Skougaard M, Hamann S, Optic Disc Drusen Studies Consortium. Peripapillary Ovoid Hyperreflectivity in Optic Disc Edema and Pseudopapilledema. Ophthalmology. 2018;125(10):1662–4. 10.1016/j.ophtha.2018.04.036 . Zhang L, Yi ZH, Jiang X, Sun GP, Zhao F, Zhang L, Xiang Y, Chen CZ. Clinical characteristics of peripapillary hyperreflective ovoid mass-like structures in myopic children. 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Retinal hemorrhages in posterior vitreous detachment. Am J Ophthalmol. 1975;80(6):1043–6. 10.1016/0002-9394(75)90334-7 . Zhang X, Cheng X, Chen B, Sun X. Multimodal Imaging Characteristics and Presumed Cause of Intrapapillary Hemorrhage with Adjacent Peripapillary Subretinal Hemorrhage. Clin Ophthalmol. 2021;15:2583–90. 10.2147/OPTH.S304861 . Zou M, Zhang Y, Huang X, Gao S, Zhang J. Demographic profile, clinical features, and outcome of peripapillary subretinal hemorrhage: an observational study. BMC Ophthalmol. 2020;20(1):156. 10.1186/s12886-020-01426-9 . Teng Y, Yu X, Dong L, Teng Y, Su Y. Clinical characteristics and pathogenesis of intrapapillary hemorrhage with adjacent peripapiilary subretinal hemorrhage. Chin J Ophthamol. 2012;48(2):131–6. Wang F. Spontaneous Focal Hemorrhage of Optic Disc in Peripapillary Hyperreflective Ovoid Mass-Like Structures. Int Med Case Rep J. 2024;17:843–7. 10.2147/IMCRJ.S473185 . Tsuda K, Oishi A, Kitaoka T. Optic disc hemorrhage in a young female following mRNA coronavirus disease 2019 vaccination: a case report. J Med Case Rep. 2022;16(1):462. 10.1186/s13256-022-03690-3 . Scott JA, Liebmann JM. Acute Onset Optic Disc Hemorrhage Following Pharmacologic Mydriasis. J Glaucoma. 2021;30(10):e379–81. 10.1097/IJG.0000000000001854 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers invited by journal 04 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Editor invited by journal 11 Aug, 2025 Submission checks completed at journal 10 Aug, 2025 First submitted to journal 10 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7272012","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512009556,"identity":"5ffe8ba5-eb08-4284-b6ef-8c3a753cea26","order_by":0,"name":"Fen Zhou","email":"","orcid":"","institution":"Nanjing Medical University Affiliated Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fen","middleName":"","lastName":"Zhou","suffix":""},{"id":512009557,"identity":"71bc0112-32db-48d2-8d36-3ec8cc810959","order_by":1,"name":"Jin Yao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYDCCAyCCR4KBn5n54APStEi2syUbkKAFCAzO85gJEKWD7/YZww8fZCzyjA8zmDEw1NhEE9QieS7HWHIGj0Sx2WGGtAcMx9JyGwhpMTjDYyDNwyORuO0ww3EDxobDRGkx/g3SsrmZsU2CWC1mYFs2MDOzEadF8gxbmSXQL4kzDrMxGyQQ4xe+M8ybb3zsqUvs7z//8cGHGhvCWhgYOAwYGHug7ATCykGA/QEDww/ilI6CUTAKRsEIBQALEzvWDjmpIgAAAABJRU5ErkJggg==","orcid":"","institution":"Nanjing Medical University Affiliated Eye Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jin","middleName":"","lastName":"Yao","suffix":""},{"id":512009558,"identity":"ff468140-0c6a-43f5-bb2e-a43af158493d","order_by":2,"name":"Qin Jiang","email":"","orcid":"","institution":"Nanjing Medical University Affiliated Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qin","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2025-08-01 14:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7272012/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7272012/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91088499,"identity":"6181a4b8-8a82-4809-9720-6ae629f60b09","added_by":"auto","created_at":"2025-09-11 12:42:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":273072,"visible":true,"origin":"","legend":"\u003cp\u003eFundus images of both eyes of patient. \u003cstrong\u003eA\u003c/strong\u003e In the affected eye, fundus photography of the right eye showed intrapapillary hemorrhage at the superior position and nasal crescent-shaped subretinal hemorrhage. \u003cstrong\u003eB\u003c/strong\u003e The yellow arrow indicated PHOMS. The red arrow denoted subretinal hemorrhage. \u003cstrong\u003eC\u003c/strong\u003e Fundus photography of contralateral eye shows nasal edge of optic disc. \u003cstrong\u003eD\u003c/strong\u003e The yellow arrow indicated PHOMS.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7272012/v1/0a1ca6462094ea8d3c2239d2.png"},{"id":91084908,"identity":"e154417f-3f83-47d3-a43c-3b3a68241e54","added_by":"auto","created_at":"2025-09-11 12:18:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":681565,"visible":true,"origin":"","legend":"\u003cp\u003eFundus photography and OCT vertical B-scan image of optic nerve head showing hemorrhages classified into 3 groups. \u003cstrong\u003eA,B\u003c/strong\u003e Group 1, The yellow arrow on fundus photography indicates DH, and the red arrow on OCT pointed to PHOMS. \u003cstrong\u003eC,D\u003c/strong\u003e Group 2, The yellow arrow on fundus photography indicated IHAPSH, and the yellow circle on OCT pointed to PHOMS. \u003cstrong\u003eE,F\u003c/strong\u003e Group 3, The yellow arrow on fundus photography indicated IHAPSH accompanied by vitreous bleeding VH, and the yellow circle on OCT pointed to PHOMS.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7272012/v1/5a5a14e1bc085e4ebcae1798.png"},{"id":91084907,"identity":"cfab95fb-cb7e-48dc-ab69-dc6357ada198","added_by":"auto","created_at":"2025-09-11 12:18:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":570822,"visible":true,"origin":"","legend":"\u003cp\u003eMultimodal imaging of IHAPSH with vitreous hemorrhage.\u003cstrong\u003e A \u003c/strong\u003eFFA showed blocked hypofluorescence due to peripapillary subretinal hemorrhag, and vitreous bleeding located around the optic disc and in the inferior vitreous cavity. \u003cstrong\u003eB \u003c/strong\u003eFundus autofluorescence showed that the optic disc and its surrounding area were obscured by hemorrhage, and no abnormal fluorescence was observed. \u003cstrong\u003eC \u003c/strong\u003eB-scan ultrasonography with low gain perpendicular to the optic nerve showed bulged optic disc (yellow arrow. \u003cstrong\u003eD\u003c/strong\u003e Hemorrhage obscured optic disc on OCT image. Elevated optic disc could be vaguely seen. The yellow arrow showed subretinal hemorrhage. \u003cstrong\u003eE\u003c/strong\u003e During the process of blood absorption, the structure of the optic disc could be clearly observed. Vertical OCT image revealed that PHOMS (red circle) with subretinal hemorrhage space (yellow arrow). \u003cstrong\u003eF\u003c/strong\u003e Horizontal OCT image showed a tilted, crowded optic disc without an obvious optic cup. Nasal optic disc elevation (red arrow) and subretinal hemorrhage (yellow arrow) could also observed.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7272012/v1/2980d5d3b9ebc2cbe57d882b.png"},{"id":91084912,"identity":"5e5dc5be-f4df-4799-b503-df2a097ecac7","added_by":"auto","created_at":"2025-09-11 12:18:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":367178,"visible":true,"origin":"","legend":"\u003cp\u003eHemorrhage absorption on fundus photography. \u003cstrong\u003eA\u003c/strong\u003e The yellow arrow indicates papillary hemorrhage. \u003cstrong\u003eB\u003c/strong\u003e Two weeks later, hemorrhage gradually absorbed. \u003cstrong\u003eC\u003c/strong\u003e After observation for three months, there was no recurrence of the optic disc hemorrhage.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7272012/v1/f4a02b74a9e579ec02daa9e6.png"},{"id":91088806,"identity":"afc5c6aa-d076-4fa5-a4ed-c2d2ac68fc52","added_by":"auto","created_at":"2025-09-11 12:50:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2910877,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7272012/v1/e10464c3-2cfd-4ca0-8ae8-0f4662992573.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical manifestations of eyes with peripapillary hyper-reflective ovoid mass-like structure presenting with optic disc hemorrhage as the initial onset","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeripapillary hyperreflective ovoid mass-like structure (PHOMS)\u0026nbsp;has received much attention in recent years. It is a special structure discovered in high-definition\u0026nbsp;enhanced depth imaging optical coherence tomography (EDI-OCT) scans of the optic disc. Currently, it is believed that it is not a unique manifestation of a single disease and can appear in various diseases. The pathological mechanism of its formation may be related to the accumulation of axonal flow in the optic nerve fibers, which leads to the protrusion of nerve fiber axons around the optic disc (1).\u0026nbsp;Previous studies have considered PHOMS as optic disc drusen (ODD), and indeed PHOMS and ODD are easily confused in ophthalmic imaging. The color fundus image of PHOMS has characteristic changes, manifested as blurred optic disc edges and a \"C\" - shaped halo. OCT shows a homogeneous mass structure outside the optic disc, above the Bruch membrane open (BMO), oval shaped, and similar to the reflex of the retinal nerve fiber layer. Typical PHOMS is oval shaped and located above the Bruch membrane adjacent to the optic disc (2-4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMyopia and optic disc tilt syndrome are more common in children with PHOMS, and are positively correlated with myopic refractive error and optic disc tilt\u0026nbsp;(5). The special structure of tilted myopic disc in PHOMS might draw the retinal and choroidal tissues over and around the elevated edge, which influences blood supply of the optic disc. Therefore, this may lead to bleeding in patients with a tilted myopic disc, which may be spontaneous or triggered by an acute event (6).\u0026nbsp;Currently, the cause of optic disc hemorrhage in PHOMS is not clear. Vascular obstruction, Bruch membrane rupture, and traction of the vitreous papilla were been proposed as possible causes (7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOptic disc and peripapillary retinal hemorrhage is a condition characterized by hemorrhages within the optic disc and surrounding retinal layers. The cause of this condition is uncertain . This may result from various factors, such as the anatomical structure of the optic disc, local vascular pressure changes, acting independently or in combination (8). Spontaneous hemorrhage of optic disc in PHOMS is a relatively rare syndrome. In some cases, bleeding within the optic disc extends into the peripapillary subretinal space or vitreous (9-10). The purpose of this study was to report on the findings of clinical features and multi-mode imaging features of PHOMS eyes with DH, which may help to identify the cause of DH. As far as I know, this is the first article in multiple sample cases to discuss DH secondary to PHOMS.\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003eStudy Design and Patients\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eTen consecutive patients with DH were identified and evaluated from July 2021 to June 2025 in Nanjing Medical University Affiliated Eye Hospital. Patients without PHOMS were also excluded. We also excluded patients with glaucoma, optic disc edema, optic neuritis, papillitis, ischemic optic neuropathy, optic nerve head drusen, or juxtapapillary neovascular membrane. All patients were followed up until the bleeding was completely resolved. The research adhered to the tenets of the Declaration of Helsinki. The institutional review board of the Nanjing Medical University Affiliated Eye Hospital approved the study. Informed consent was obtained from all participants.\u003c/p\u003e\u003cp\u003eMedical and ocular history, ocular examination, and ancillary tests were performed for each patient. All patients underwent ophthalmic examinations performed by skilled technicians, including slit-lamp microscopy, IOP measurement, BCVA assessment, fundus color photography using a Topcon (Japan) fundus camera, optic nerve head OCT imaging (utilizing the single line scan mode) performed with Heidelberg Spectralis HRA OCT (Heidelberg Engineering, Germany), FFA and FAF imaging using Heidelberg confocal scanning laser ophthalmoscopy (CSLO) system (Heidelberg Engineering, Germany), and B-scan ultrasonography using a Tianjin Meda ODM-2100S ophthalmic A/B ultrasound scanner. The results were independently analyzed and interpreted by two retinal specialists.\u003c/p\u003e\u003cp\u003eAll patients took He Xue Ming Mu tablets to relieve hemorrhage. No other special treatments were given to the patients. They were closely observed throughout the follow-up period. Irregular follow-up was performed until the hemorrhage had completely resolved.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn our study, 10 affected eyes of 10 patients were included. Clinical features were summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patient age ranged from 12 to 42 years (mean, 24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 years). There were 8 females (80%) and 2 males (20%). All patients had an acute onset of visual symptoms at presentation, including floaters with or without mild blurred vision. Four patients experienced mild vision impairment, while the vision of 6 patients was 1.0. All patients had no systemic diseases, no vasculitis or trauma history. The intraocular pressure was within normal limits. The anterior segments were normal. Moreover, the patients did not experience any Valsalva manoeuvre. None of patients showed disc drusen; abnormal intraretinal, intrapapillary, or choroidal vasculature; or subretinal neovascularization after hemorrhage absorption.\u003c/p\u003e\u003cp\u003eAll patients had myopia and tilted disc. Four eyes had high myopia (spherical equivalent\u0026thinsp;\u0026ge;\u0026thinsp;6.0 diopters), 4 eyes had moderate myopia (spherical equivalents of 3.0\u0026ndash;6.0 diopters) and 2 eyes had mild myopia (spherical equivalents of 0.25\u0026ndash;2.75 diopters). Nine patients had bilateral PHOMS presentation and one patient had unilateral involvement. PHOMS can be observed on all affected eyes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, C). Nine patients had PHOMS presentation in contralateral eyes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, D). According to the dilated fundus evaluation, we classified the fundus performance into 3 groups: isolated DH (3 eyes, 30%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-B), IHAPSH (3 eyes, 30%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC-D), and IHAPSH with vitreous hemorrhage (4 eyes, 40%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE-F). Hemorrhage within the disc and adjacent subretinal hemorrhage were located nasally in 7 eyes, superiorly in 2 eyes, and inferiorly in 1 eye.\u003c/p\u003e\u003cp\u003eFluorescein angiography was performed in 10 eyes. FFA showed blocked hypofluorescence due to peripapillary subretinal hemorrhage (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Vitreous bleeding located around the optic disc and in the inferior vitreous cavity in 4 patients. Five eyes had mild disc staining fluorescence in late stage. It was diffcult to assess disc staining because of a large area of blockage from extensive superficial and peripapillary subretinal hemorrhage in 5 eyes. Fundus autofluorescence showed that the optic disc and its surrounding area were obscured by hemorrhage, and no abnormal fluorescence was observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). B-scan ultrasonography showed bulged optic disc (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). In 2 patients, hemorrhage obscured optic disc on OCT image (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). However, elevated optic disc could be vaguely seen. OCT demonstrated the nasal optic disc protrusion and subretinal hemorrhage was seen. After complete hemorrhage absorption, the structure of the optic disc could be clearly observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE-F).\u003c/p\u003e\u003cp\u003eAll patients had a good prognosis without any special treatments. The vision of 6 patients remained unchanged, while that of 4 patients improved to 1.0. The symptoms in all cases relieved in 2 weeks which may be due to the absorption of vitreous hemorrhage. The absorption of bleeding varied depending on the type of bleeding. The durations of hemorrhage absorption in DH, IHAPSH, and IHAPSH with vitreous hemorrhage were 21.3 days, 81.7 days, and 112.3 days, respectively. The mean hemorrhage resolved at 75.8 days after initial presentation. Regardless of the location, the hemorrhage in all cases faded. There have been no recurrences of intrapapillary hemorrhage in the same eye during the follow-up period (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA-C).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Characteristics and Clinical Findings of the Patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAffected eye\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMyopia (Diopters)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePHOMS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBCVA baseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAbsorption time (day)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003eHemorrhage Location\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOptic disc hemorrhage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eperipapillary hemorrhage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eVitreous\u003c/p\u003e\u003cp\u003ehemorrhage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd 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colname=\"c9\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eR\u0026amp;L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eR\u0026amp;L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eR\u0026amp;L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this was the first study to describe the characteristics of PHOMS-related DH. DH was found both in glaucoma and posterior vitreous detachment (PVD). PVD-related optic disc hemorrhage presented in three types：flame, splinter, and dot or blot shape. Flame-shaped DH was majorly observed in the PVD group\u0026nbsp;(11-12). In contrast, glaucomatous DH was commonly splinter-shaped. To date, a few of studies have reported optic disc hemorrhage associated with structural abnormalities of the optic disc, such as a small disc, tilted disc, or optic disc drusen\u0026nbsp;(13-14). Due to the oblique insertion of the nerve into the sclera of the posterior staphyloma, the discs in myopic eyes appear tilted. This tilting results in elevation of the superior and nasal margin of the disc. Dragging of the retinal and choroidal tissues over and around the elevated edge put capillaries at risk for bleeding\u0026nbsp;(20). IHAPSH was a common\u0026nbsp;optic disc hemorrhage\u0026nbsp;in patients with optic disc shape abnormalities\u0026nbsp;(15). IHAPSH was also observed in patient with PVD\u0026nbsp;(16-17). Takemoto et al. reported that 5 patients diagnosed with IHAPSH and OCT revealed PHOMS in all cases\u0026nbsp;(14).\u0026nbsp;In\u0026nbsp;previous study, the fundus features of the tilted optic disc eyes showed peripapillary subretinal hemorrhage (PSH) alone,\u0026nbsp;IHAPSH, and\u0026nbsp;IHAPSH\u0026nbsp;with vitreous hemorrhage\u0026nbsp;(18). Based on the bleeding area in our series, the hemorrhages were classified as: isolated DH (30%),\u0026nbsp;IHAPSH\u0026nbsp;(30%), and\u0026nbsp;IHAPSH\u0026nbsp;with vitreous hemorrhage (40% ). We did not find the type of optic disc hemorrhage, such as PSH alone. However, in our case series, vitreous hemorrhage was present in 40% of the patients. All the bleeding patients were spontaneous. Moreover, hemorrhage could occur at any location on the optic disc except temporal side of the optic disc. It was speculated that the location of the bleeding is related to the degree of optic disc bulge which is more obvious on the nasal side.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIHAPSH most commonly occured in Asian patients, especially in high myopia eyes\u0026nbsp;(19). Our study showed that intrapapillary hemorrhage occurs most commonly in young healthy patients ranging from teenagers to adults with an average age of 24.6 years. This case series demonstrated a female predominance of 80%. Kokame et al. reported that the patients are often female (78%)\u0026nbsp;(8). In previous study, 68% of eyes were in female patients and the mean patient age was 20 years\u0026nbsp;(18). This is consistent with two reports. Our research indicated all patients had myopia. Four eyes had high myopia (spherical equivalent\u0026nbsp;≥\u0026nbsp;6.0 diopters), 4 eyes had moderate myopia (spherical equivalents of 3.0–6.0 diopters) and 2 eyes had mild myopia (spherical equivalents of 0.25–2.75 diopters). The onset was sudden and unilateral, but symptoms were mild, predominantly manifesting as floaters and mild vision loss. There was no anterior segment or vitreous inflammation. The fundus showed a small, crowded optic disc with a small cup or no cup, and disc tilting. The disc margin might be slightly elevated and blurred nasally. Mild cases present with optic disc bleeding on the disc surface, while severe cases might present with IHAPSH. A well-demarcated, dark red, crescent-shaped subretinal hemorrhage was visible superior-nasal to the disc, encircling one-third to two-thirds of the disc rim. Hemorrhage could also be observed in the vitreous cavity. B-scan ultrasonography showed mild optic disc elevation without the calcified shadow characteristic of optic disc drusen. A minority of patients exhibit vitreoretinal adhesion or traction. OCT demonstrated optic disc elevation with hemorrhagic neurosensory detachment. FFA revealed that both the disc surface hemorrhages and the subretinal hemorrhage block fluorescence. The course and filling of retinal vessels were normal. In the late phase, the elevated disc might show slight fluorescein staining. Additionally, there was no autofluorescence or other abnormal fluorescence. When vitreous hemorrhage was merged, it might manifest as a boundary-blurred fluorescence blockage anterior to the retina. In the late phase of angiography, fluorescein staining was observed in the central portion of the optic disc without significant fluorescein leakage.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This disease was a self-limiting condition. Hemorrhages spontaneously resolved without any particular treatment and complications with preserved visual acuity and optic nerve function. Kokame et al. reported that IHAPSH has a good prognosis with no sequelaes. Hemorrhage spontaneously resolved within 1–7 months (mean, 2 months) (8). Zeng R et al. reported that hemorrhage resolved at 2 months after initial clinical symptoms (9). Zou M\u0026nbsp;et al. reported that the mean durations of hemorrhage absorption in IHAPSH was 2.53 months (18). In our case, the hemorrhage resolved at 75.8 days after initial presentation and the visual acuity completely recovered. Moreover, previous studies have shown that visual acuity maintained or improved in most cases and subretinal hemorrhage resolves spontaneously without sequelae in IHAPSH patients (8-9, 18,20). Therefore, after definitive diagnosis, observation with monitoring for hemorrhage resolution was appropriate to avoid unnecessary interventions. However, optic disc hemorrhage required differentiation from other diseases. A previous study investigated optic disc hemorrhage following the COVID-19 vaccination (21). They reported that an 18-year-old Japanese female developed optic disc hemorrhage after vaccination. Scott JA et al. had reported DH occurred after pupillary dilation (22). Moreover, valsalva maneuvers were another possible cause that may predispose patients to bleeding from the optic discs. This condition presented with a \"boat-shaped\" preretinal hemorrhage. Massive hemorrhage might extend into the vitreous cavity to obscure vision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study is the first to analyze the clinical characteristics of a series of patients with DH combined PHOMS, and the patients included in the study have a large age range. At the same time, by observing the imaging features of different examination methods and combining multimodal imaging results, they can not only play to their own characteristics, but also complement each other's shortcomings, better helping clinicians to differentiate and diagnose PHOMS. However, this study also has shortcomings: the sample size is small, the time span for collecting patients is large, and this study is a retrospective study. In conclusion, correct diagnosis is particularly important to avoid unnecessary clinical mistherapy and anxiety in patients with DH combined PHOMS.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo provide patients with the most appropriate care and treatment, this report will help clinicians identifying the causes of optic disc hemorrhage and avoid unnecessary and invasive examinations and treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDH \u0026nbsp; \u0026nbsp; \u0026nbsp;Optic disc hemorrhage\u003c/p\u003e\n\u003cp\u003ePHOMS \u0026nbsp;Peripapillary hyperreflective ovoid mass-like structures\u003c/p\u003e\n\u003cp\u003eBCVA \u0026nbsp; \u0026nbsp;Best-corrected visual acuity\u003c/p\u003e\n\u003cp\u003eIOP \u0026nbsp; \u0026nbsp; \u0026nbsp; Intraocular pressure\u003c/p\u003e\n\u003cp\u003eOCT \u0026nbsp; \u0026nbsp; Optical coherence tomography\u003c/p\u003e\n\u003cp\u003eFAF \u0026nbsp; \u0026nbsp; Fundus autofluorescence\u003c/p\u003e\n\u003cp\u003eFFA \u0026nbsp; \u0026nbsp; Fundus fluorescein angiography\u003c/p\u003e\n\u003cp\u003eIHAPS \u0026nbsp;Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEDI-OCT \u0026nbsp;Enhanced depth imaging optical coherence tomography\u003c/p\u003e\n\u003cp\u003eODD \u0026nbsp; \u0026nbsp;Optic disc drusen\u003c/p\u003e\n\u003cp\u003eBMO \u0026nbsp; \u0026nbsp;Bruch membrane open\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePVD \u0026nbsp; \u0026nbsp;Posterior vitreous detachment\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by institutional review board of the Nanjing Medical University Affiliated Eye Hospital. Written informed consent to participate in this study was provided by the participants’ legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict on interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFZ collected the data and wrote the first draft of the manuscript. QJ and JY reviewed and revised the manuscript and produced the final version. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the National Natural Science Foundation (grant number 82070983)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMalmqvist L, Sibony PA, Fraser CL, Wegener M, Heegaard S, Skougaard M, Hamann S, Optic Disc Drusen Studies Consortium. Peripapillary Ovoid Hyperreflectivity in Optic Disc Edema and Pseudopapilledema. Ophthalmology. 2018;125(10):1662\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ophtha.2018.04.036\u003c/span\u003e\u003cspan address=\"10.1016/j.ophtha.2018.04.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang L, Yi ZH, Jiang X, Sun GP, Zhao F, Zhang L, Xiang Y, Chen CZ. 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J Glaucoma. 2021;30(10):e379\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/IJG.0000000000001854\u003c/span\u003e\u003cspan address=\"10.1097/IJG.0000000000001854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"PHOMS, DH, IHAPSH, Vitreous hemorrhage, Clinical characteristics, Multimodal imaging features","lastPublishedDoi":"10.21203/rs.3.rs-7272012/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7272012/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo observe the clinical manifestations in eyes presenting with optic disc hemorrhage (DH) as the initial sign, which were found to have peripapillary hyperreflective ovoid mass-like structures (PHOMS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective observational study. Ten eyes of 10 patients diagnosed with DH combined with PHOMS at the Eye Hospital of Nanjing Medical University between January 2021 and May 2025 were enrolled. There were 2 male and 8 female patients. PHOMS was bilateral in 9 patients and unilateral in 1 patient. The mean age was 24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 years (range: 12\u0026ndash;42 years). All affected eyes underwent best-corrected visual acuity (BCVA) testing, intraocular pressure (IOP) measurement, color fundus photography, B-scan ultrasonography, optical coherence tomography (OCT), fundus autofluorescence (FAF), and fundus fluorescein angiography (FFA).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll patients experienced an acute onset of visual symptoms. Symptoms were mild, predominantly manifesting as floaters and mild vision loss. All patients had myopia and tilted disc. Four eyes had high myopia, 4 eyes had moderate myopia and 2 eyes had mild myopia. PHOMS was detected in 10 patients presenting with DH, and PHOMS was also identified in the contralateral eye in 9 of these patients. Based on bleeding area, the hemorrhages were classified as: isolated DH (3 eyes, 30%), Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH) (3 eyes, 30%), and IHAPSH with vitreous hemorrhage (4 eyes, 40%). Hemorrhage within the disc and adjacent subretinal hemorrhage were located nasally in 7 eyes, superiorly in 2 eyes, and inferiorly in 1 eye. Hemorrhage spontaneously resolved within 14 to 128 days (mean, 75.8\u0026thinsp;\u0026plusmn;\u0026thinsp;41.2), and there were no recurrent hemorrhages. Visual acuity recovered to 1.0 in all patients after observation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eDH combined with PHOMS predominantly affects one eye in female patients. It could be classified by hemorrhage severity as isolated DH, IHAPSH, or IHAPSH combined with vitreous hemorrhage. The hemorrhagic phenomena resolved spontaneously without any specific treatment, and visual acuity recovered well.\u003c/p\u003e","manuscriptTitle":"Clinical manifestations of eyes with peripapillary hyper-reflective ovoid mass-like structure presenting with optic disc hemorrhage as the initial onset","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 12:18:15","doi":"10.21203/rs.3.rs-7272012/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-16T15:44:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251810670792910778384760342276163630945","date":"2025-09-15T14:31:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T11:01:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T06:29:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-11T06:23:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-10T07:30:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-08-10T07:27:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bbb4a16f-d02a-4bee-ae37-e2a693618567","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-11T12:18:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 12:18:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7272012","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7272012","identity":"rs-7272012","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}