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Editors Selection IGR 17-3

Clinical Forms of Glaucoma: (Peri)papillary hemorrhages in Pathologic Myopia

Comment by Jost Jonas on:

106406 Papillary and Peripapillary Hemorrhages in Eyes With Pathologic Myopia, Xiong J; Du R; Xie S et al., Investigative Ophthalmology and Visual Science, 2022; 63: 28

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Since the landmark study by Stephan Drance in 1970, optic disc hemorrhages have been recognized as strongly related to the progression of glaucomatous optic neuropathy, in addition to occurring in association with an acute posterior vitreous detachment and other conditions.^1,2 In this article by Ohno-Matsui and her team, out of a very large group of 3774 eyes with pathologic myopia, 97 (4.05%) eyes had hemorrhages in the optic nerve head region. The hemorrhages were located in the parapapillary gamma zone and delta zones without contact to the optic disc border in 49 (54%) eyes. Thirty eyes recurrently showed hemorrhages. Associated factors for the hemorrhages were longer axial length, lower stage of myopic macular degeneration, and an assumed or potential glaucoma-like optic nerve damage. This profound clinical cross-sectional and longitudinal study is a treasure of clinical information. It shows the variation in hemorrhages occurring in the intrapapillary and parapapillary region. As discussed by the authors, the parapapillary hemorrhages may be due to a stretching of the retinal tissue and retinal vessels in the gamma zone and delta zone, in which the retina consists only of the retinal nerve fiber layer, retinal vessels and the inner limiting membrane, and in which the tissue is stretched by the amount of the width of gamma/delta zone. Correspondingly, a longer axial length (correlating with larger gamma/delta zone), a temporal location (where usually gamma/ delta zones are largest), and a lower degree of myopic macular degeneration (which can inversely correlate with the size of gamma/delta zone) were risk factors for parapapillary hemorrhages. The location of hemorrhages at a scleral ridge fit with the notion, as the scleral ridge is related to a large gamma/delta zone. The parapapillary type of hemorrhages, without contact to the optic disc border, may not be related to glaucoma. The optic disc-related hemorrhages as compared to the parapapillary ("conus-related") hemorrhages had a lower prevalence (1.47% versus 2.81%), not far from the prevalence of about 1% reported for normal eyes in population-based studies.^2,3 Interestingly, none of the hemorrhages were reported to be associated with cotton-wool spots in their vicinity, speaking against a direct ischemic pathogenesis of the hemorrhages.

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