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      Controversies in the association of parapapillary atrophy with glaucoma

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          Abstract

          Parapapillary atrophy is a condition which is seen in around 70% of normal individuals. Classically divided into zone alpha and beta, recently, it has been further categorized into zone gamma and delta. Some of these zones of parapapillary atrophy are more prevalent and larger in size in glaucoma patients. Studies have also found the rate of progression of glaucomatous change to be faster in patients with this anomaly. This condition is of clinical significance in glaucoma suspects, as it could be another pointer indicating potential risk of converting to glaucoma. On the contrary, there are other studies which question the relevance of these clinical features in glaucoma patients. In the light of these conflicting reports, it becomes an interesting exercise to explore this controversial area further. This review attempts to determine the role of parapapillary atrophy and its relevance with glaucoma. With this purpose, an online search for this term was conducted on search engines such as PubMed, Google Scholar, and others.

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          Most cited references48

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          Microstructure of parapapillary atrophy: beta zone and gamma zone.

          To examine the morphologic features of parapapillary atrophy by using enhanced depth imaging optical coherence tomography (EDI-OCT) and color fundus photographs.
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            Parapapillary chorioretinal atrophy in normal and glaucoma eyes. I. Morphometric data.

            Glaucomatous optic nerve damage is associated with alterations of the intra- and parapapillary optic disc area. We measured and compared the parapapillary region in 582 eyes of 321 patients suffering from chronic primary open-angle glaucoma and in 390 eyes of 231 normal subjects. Only one randomly assessed eye per patient and subject was taken for statistical analysis. Highly mopic eyes with a myopic refractive error of more than -8.00 diopters had been excluded. The parapapillary chorioretinal atrophy was divided into a peripheral zone "Alpha" with irregular hyper- and hypopigmentation, and a more central zone "Beta" characterized by whitish colour, visible large choroidal vessels and visible sclera. In the normal eyes both zones were significantly (P less than 0.001) largest and most common in the temporal horizontal sector, followed by the inferior temporal sector, the superior temporal sector and finally the nasal sector. In the glaucoma group both zones were significantly larger (P less than 0.0001; Mann-Whitney test) and more frequent than in the normal eyes (0.40 +/- 0.32 mm2 versus 0.65 +/- 0.49 mm2 for zone Alpha, 0.13 +/- 0.42 mm2 versus 0.79 +/- 1.17 mm2 for zone Beta). The differences were significant also for the earliest glaucoma stage of this study. They were most marked for the nasal parapapillary sector. Significant differences (P less than 0.001) between the normal group and the earliest glaucoma stage were: zone Alpha larger than 0.20 mm2 or broader than 0.20 mm in the temporal horizontal sector, total area of zone Alpha larger than 0.30 mm2, occurrence of zone Alpha in the nasal sector, and occurrence of zone Beta anywhere.
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              Parapapillary Atrophy: Histological Gamma Zone and Delta Zone

              Background To examine histomorphometrically the parapapillary region in human eyes. Methodology/Principal Findings The histomorphometric study included 65 human globes (axial length:21–37 mm). On anterior-posterior histological sections, we measured the distance Bruch's membrane end (BME)-optic nerve margin (“Gamma zone”), BME-retinal pigment epithelium (RPE) (“Beta zone”), BME-beginning of non-occluded choriocapillaris, and BME-beginning of photoreceptor layer. “Delta zone” was defined as part of gamma zone in which blood vessels of at least 50 µm diameter were not present over a length of >300 µm. Beta zone (mean length:0.35±0.52 mm) was significantly (P = 0.01) larger in the glaucoma group than in the non-glaucomatous group. It was not significantly (P = 0.28) associated with axial length. Beta zone was significantly (P = 0.004) larger than the region with occluded choriocapillaris. Gamma zone (mean length:0.63±1.25 mm) was associated with axial length (P 50 µm diameter within gamma zone) was present only in highly axially elongated globes and was not related with glaucoma. Beta zone (Bruch's membrane without RPE) was correlated with glaucoma but not with globe elongation. Since the region with occluded choriocapillaris was smaller than beta zone, complete loss of RPE may have occurred before complete choriocapillaris closure.
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                Author and article information

                Journal
                Taiwan J Ophthalmol
                Taiwan J Ophthalmol
                TJO
                Taiwan Journal of Ophthalmology
                Wolters Kluwer - Medknow (India )
                2211-5056
                2211-5072
                Oct-Dec 2020
                31 October 2019
                : 10
                : 4
                : 243-249
                Affiliations
                [1] Ajmal Khan Tibbiya College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
                Author notes
                [* ] Address for correspondence: Dr. Syed Shoeb Ahmad, Ajmal Khan Tibbiya College, Aligarh Muslim University, Aligarh - 202 001, Uttar Pradesh, India. E-mail: syedshoebahmad@ 123456yahoo.com
                Article
                TJO-10-243
                10.4103/tjo.tjo_64_19
                7787084
                33437595
                9b74c6bb-7fe8-4ede-b458-36b5b1c3fcc0
                Copyright: © 2020 Taiwan J Ophthalmol

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 27 May 2019
                : 28 August 2019
                Categories
                Review Article

                glaucoma,optic disc,peripapillary atrophy
                glaucoma, optic disc, peripapillary atrophy

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