A 65-year-old man in Brazil spent a week with a left eye that was painful, red, and losing vision. When ophthalmologists at the Federal University of São Paulo examined the eye, they saw layered bands of cells stacked at the front of the eye, a pattern known as the candy-stripe sign. The image, published online Aug. 6 in JAMA Ophthalmology, is a classic calling card of ghost cell glaucoma.
The condition's defining twist is timing. Ghost cell glaucoma follows bleeding inside the eye, and the pressure spike often arrives weeks to months later. By then, the original bleed may be forgotten, or it may never have been noticed at all.
That delay matters most for people with conditions that cause eye bleeds. Diabetes sits near the top of that list.
The Delay Built into an Eye Bleed
Ghost cells are red blood cells that have broken down after bleeding into the vitreous, the clear gel that fills the back of the eye. The American Academy of Ophthalmology's EyeWiki entry on ghost cell glaucoma says patients typically arrive with pressure spikes one to three months after a vitreous hemorrhage caused by trauma, surgery, or existing retinal disease.
The slow pace reflects how the eye handles blood. A 1997 review by Emory University pathologists found that blood in the vitreous clots quickly but then clears at only about 1% per day. As trapped red cells lose their hemoglobin, they become small, stiff, khaki-colored ghosts. If the thin barrier at the front of the vitreous has been disrupted, they can drift forward and jam the eye's drainage tissue.
The candy-stripe look appears when fresh blood is present, too. Heavier fresh red cells settle to the bottom, while a lighter khaki layer of ghost cells rests on top. EyeWiki notes that eye pressure in this condition can climb as high as 60 to 70 mm Hg, far above the normal range and high enough to make the cornea swell.
Diabetes Is a Leading Source of Vitreous Bleeding
The published summary of the São Paulo case does not say what caused the man's bleed, and it should not be assumed that diabetes was involved. In the wider population, though, spontaneous bleeding into the vitreous often traces back to damaged retinal blood vessels.
In the Emory review, proliferative diabetic retinopathy, the advanced stage in which fragile new vessels grow on the retina, accounted for about 32% of spontaneous vitreous hemorrhages, the largest single share. Retinal tears caused about 30%, abnormal vessel growth after retinal vein blockages about 11%, and vitreous detachment without a tear about 8%.
Diabetic eye disease is widespread in the United States. A team led by CDC researchers estimated that 9.60 million Americans had diabetic retinopathy in 2021, about 26% of people with diabetes. Roughly 1.84 million had vision-threatening disease, a category that includes proliferative retinopathy as well as swelling in the center of the retina.
The researchers found marked differences between states. They also warned that the burden may grow in coming decades as diabetes becomes more common among both young people and adults.
None of this means most people with diabetic retinopathy will develop ghost cell glaucoma. The condition is uncommon, and EyeWiki notes that having ghost cells in the eye does not necessarily lead to glaucoma. It does mean the pool of people with a possible trigger is not small.
Surgery and Injury Can Start the Clock Too
Eye injuries and procedures can also set the process in motion, both by causing bleeding and by breaching the membrane that normally keeps old blood in the back of the eye. EyeWiki lists trauma, cataract surgery, certain laser procedures and conditions such as sickle cell disease among the reported triggers.
In diabetic eye care, the condition is familiar enough to appear on surgeons' lists. A 1992 review of diabetic vitrectomy, an operation to remove the vitreous gel, named ghost cell glaucoma among the less common reasons to operate.
The delay creates a practical trap. Someone who had an eye injury, cataract surgery or a diabetic bleed weeks earlier may not connect new pain and blurred vision to that event. The condition can also be mistaken for inflammation or infection inside the eye, which is why recognizing the khaki cells matters.
Treatment Usually Works, but Speed Matters
EyeWiki describes ghost cell glaucoma as typically temporary, lasting until the supply of ghost cells in the vitreous runs out, which can take months. Doctors usually start with pressure-lowering medications. When those are not enough, surgeons can wash the cells out of the front of the eye, remove old blood with a vitrectomy or, in stubborn cases, create a new drainage route.
The real danger is sustained high pressure, which can damage the optic nerve. The sooner it is caught, the more options doctors have to protect vision.
The JAMA Ophthalmology report is a single image-based case, so it cannot show how often the condition develops or how this patient fared. The broader medical literature, however, is consistent on the timing.
People who have had a recent eye bleed, eye injury or eye surgery should keep the follow-up schedule their eye doctor sets, even if they feel fine. People with diabetes should keep up with recommended eye exams. Sudden eye pain, redness or vision loss calls for prompt evaluation by an eye care professional.
Key Questions Answered
What is ghost cell glaucoma?
It is a form of glaucoma in which degenerated red blood cells from an earlier eye bleed clog the eye's drainage tissue and raise the pressure inside the eye.
Why can it appear weeks or months after the bleed?
Blood in the vitreous clears slowly, and red cells take time to break down into stiff ghost cells. Pressure spikes typically come one to three months after the hemorrhage.
How is diabetes connected?
Proliferative diabetic retinopathy is the largest single cause of spontaneous bleeding into the vitreous, which is the usual starting point for ghost cell glaucoma.
Is ghost cell glaucoma common?
No. It is uncommon, and having ghost cells in the eye does not always lead to glaucoma.
What caused the bleed in the São Paulo case?
The published summary does not say, and it should not be assumed, that diabetes was involved.
What should people with a recent eye bleed or surgery watch for?
New eye pain, redness or blurred vision warrant prompt evaluation, along with keeping all scheduled follow-up visits.
Published by Medicaldaily.com
