Interesting.  I see what looks like fine neovascularization which
appears to be associated with the bleeding.  No cupping, so I feel
comfortable in ruling out glaucoma.  Blood vessels exhibit tortuosity,
along with A/V nicking.  Hypertension?  Diabetes?

DrG

Were the visual fields normal?  Interesting that the splinter
hemorrhage
has not changed over a year's time.

frank

Sure.  Lots.

First thought is that it is a Drance hemorrhage.  However, it is
unlikely that it would remain so similar in appearance, or reappear in
the same spot with similar appearance a year from now.

It looks like the retinal nerve fiber layer is nice and thick in that
area on both optic nerve photographs (especially the 1st one); a
clearer picture for "today's" would obviously be nicer, as would
red-free photographs.  Even better would be stereoscopic pairs.

Neural rim tissue size is normal.  Optic nerve size is normal.  PPA
(appears to be esclusively zone alpha type)  and scleral cup makes
inferior edge of optic nerve hard to judge (PPA may go from 2:30 to
5:00 or may go to 7:00) -- it may be thin down there depending on
where the crescent (hidden by blood) ends.  Optic nerve cupping
basically obeys ISNT rule if no scleral crescent/PPA present
inferiorly.

Check the blood pressure.  I see no obvious A/V nicking, Salus' or
Gunn's signs.  A/V ratio may be slightly less than 2/3, but if
present, is subtle (compare caliber of inferior CRV @6:00 to inferior
CRA @ 4:00).

And looking at it more closely, especially on the second photograph, I
suspect NVD.  I essentially made both pics "red free" in Photoshop and
placed them side by side.  It is obviously and unquestionably *worse*
today.  Area at 6:00 on photo 1 appears pretty normal on colorized
photo, but appears to be fine wispy NVD on red-free (could be
artifact).  It makes me suspect NVD even more.

Bring her back:  Carefully check before dilation for NVI and perform
gonioscopy to rule out neovascularization of the angles (IOP is low,
but check anyways) -- use Zeiss-type 4-mirror gonioprism so you don't
mess up the clarity of the cornea for your photos/fundus eval.  It is
unusual to have NVD without NPDR changes, but it can happen.  In cases
where I don't get a clear view with a fundus camera or a non-contact
fundus lens (rare), I would slap on a contact lens for best image
detail (*after* fundus photos).  Hruby lens has been great at times
too, believe it or not for certain cases.  Even a good old direct
ophthalmoscope can give a different view that may provide clues.

I would send her off to her internist to rule out diabetes, if she is
not a known diabetic.  If she is, I would find out want to know her
hemoglobin A1C and current blood glucose levels.

An IVFA would be able to definitely diagnose between a Drance heme or
NVD (late leakage).  I would send her off to a retinal specialist; it
is close to the level of high-risk PDR, if it is NVE.

Other rarer causes would be ocular ischemic syndrome or a
hemoglobinopathy (such as sickle cell or sickle cell trait).  I really
doubt that.

I say NVD secondary to diabetes mellitus.

Other comments:  I agree with optic nerve cupping assessment of 0.6.

Interesting case.