What Ophthalmology Residents Should Know About Flame Hemorrhages

Apr 7, 2021
11 min read

What are flame hemorrhages?

Flame hemorrhages are a subset of retinal hemorrhages occurring within the retinal nerve fiber layer.1 They are related to pathologies of the superficial retinal capillary plexus,1 including hypertensive retinopathy and retinal venous occlusion.2,3

In general, hemorrhages are precipitated by breakdown of vessel walls; wall instability etiologies can include: physical pressure from trauma or surgery, increased pressure within the vessels, wall inflammation, weak connective tissue, and/or systemic coagulation pathologies.4

Flame hemorrhages on exam

On exam, flame hemorrhages are usually found in the posterior pole of the retina;4 they may be around the optic nerve in diseases such as glaucoma.2 However, they are uncommon in the periphery of the retina, unlike another form of retinal hemorrhages called “dot and blot” hemorrhages.5

Flame hemorrhages are typically red in color and elliptical or “lozenge” shaped.4 The outer rim of flame hemorrhages is not completely smooth; some parts will be serrated4 or feathery in appearance.2

Flame hemorrhages should not be confused with other retinal hemorrhages of the retinal nerve fiber layer: Roth spots and disc hemorrhages. Roth spots have a white center and their shape is rounder. Disc hemorrhages have a splinter shape that becomes narrower as its ends approach the optic disc.1

Flame hemorrhage formation pathophysiology

The more elongated, linear shape of these hemorrhages is produced by the pattern of blood movement as it infiltrates the nerve fiber layer. The blood mirrors the parallel arrangement of the axons5 of the retina in an arching pattern on both sides of the fovea in accordance with the positioning of the retinal nerve fiber bundles.6

Differential diagnosis of flame hemorrhage

When a flame hemorrhage is found on exam, it can be difficult to determine its underlying etiology because there are many possibilities. While this is not an exhaustive list, some conditions that should be kept in mind, based on current literature and case reports, are as follows:

Infectious etiologies

  • Acute bacterial endocarditis1
  • Dengue fever7
  • Hemolytic uremic syndrome8
  • Post-fever retinitis
    • Potential consequence of systemic infections such as West Nile fever, Rickettsiosis, Typhoid fever and Rubella. Researchers are not sure whether the retinitis here is infection or immune-mediated (or both).9
  • Acquired Immunodeficiency Syndrome (AIDS)10

Microvascular etiologies

  • Hypertensive retinopathy,1, including underlying issues such as:
    • malignant hypertension11
    • hypertensive emergencies12
    • pregnancy-induced hypertension13
  • Glaucoma14
  • Aneurysmal subarachnoid hemorrhage15
  • Branch retinal vein occlusions5
  • Papilledema16
  • Collagen vascular disease16

Autoimmune etiologies

  • Diabetic retinopathy17
  • Systemic sarcoidosis18
  • Lupus19
  • IRVAN (idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome) with p-ANCA positivity20

Hematologic etiologies

  • Hematologic cancers
    • Leukemia1
    • Multiple myeloma21
  • Anemias21
    • Aplastic anemia
    • Pernicious anemia
    • Iron deficiency anemia
    • Megaloblastic anemia
    • Hemolytic anemia
  • COVID, with high D-dimer22
  • Thrombocytopenia16
  • Anoxia16
  • Coagulopathies16

Traumatic etiologies

  • Birthing-mediated traumas (e.g., instrument-assisted)23
  • Dental procedures (ie., that can lead to branch retinal artery occlusion)24
  • Coronary artery bypass graft (possible relation to ischemic optic neuropathy, for instance)25
  • Shaken baby syndrome26
  • Blunt trauma16

Miscellaneous etiologies

  • Retinopathy of prematurity27
  • After certain medications
    • One case report described flame hemorrhages in a patient after beginning fingolimod for Multiple Sclerosis28
  • Thiamine deficiency-induced Wernicke encephalopathy29
  • Radiation16


Because most flame hemorrhages do not involve the fovea, they will not lead to blindness and can just be observed.1 This is particularly true if there is a single flame hemorrhage found on exam; in that case, further ocular-specific management can focus on watching for progression, signs of ischemia, and neovascularization.1

The main focus will then be on determining the basis of the flame hemorrhage. Most flame hemorrhages will typically resolve after addressing the systemic predispositions in a patient. Thus, it is critical to use an interprofessional team to assess and treat the patient.1

An important aspect of determining how to determine follow-up in patients is getting a thorough history. Discussion questions should address social history, medications, any trauma, or recent changes in vision, for example.1

After a history, a typical ophthalmic examination for evaluation of flame hemorrhages should involve: slit lamp examination, dilated fundoscopy, and intraocular pressure measurements.1

In terms of further workup to rule out any systemic conditions, referrals should be made so that the patient can have etiology-specific labs drawn. For example, patient levels of serum lipids, plasma proteins, and plasma glucose should be checked to evaluate for metabolic syndrome.1

Blood viscosity should be evaluated via measurement of hemoglobin, hematocrit, and fibrinogen. If there is a concern for an autoimmune basis to hyperviscosity, measurements of protein C, protein S, factor V leiden, homocysteine, and antithrombin III should be performed.30 Coagulation factors and M-type globulins can also be checked to evaluate for hemorrhages in the setting of multiple myeloma.31

If flame hemorrhages are suspected to be secondary to hypertension, blood urea nitrogen, workup for basic electrolyte levels, creatinine clearance, urine samples, and renal imaging is reasonable.31 In cases of retinopathy in the setting of hypertensive crises, labetalol is typically the first line for management.32

Birth trauma-induced retinal hemorrhages in newborns can be managed conservatively; they typically normalize in 2-4 weeks. However, if the patient is younger than 3 years and has retinal hemorrhages in addition to an intracranial injury, there should be high suspicion for child abuse.1


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