Long-term pattern of progression of myopic maculopathy: a natural history study. Ophthalmology. 2010;117:1595-1611, 1611.e1-e4. [PMID: 20207005 DOI: 10.1016/j.ophtha.2009.11.003]

Comparison of Intravitreal Aflibercept and Ranibizumab for Treatment of Myopic Choroidal Neovascularization: One-Year Results-A Retrospective, Comparative Study

Purpose

To compare one-year treatment outcomes of intravitreal aflibercept (IVA) and intravitreal ranibizumab (IVR) for treatment of myopic choroidal neovascularization (mCNV).

Methods

The medical records of a total of 30 eyes diagnosed with mCNV and underwent IVA or IVR treatment for a minimum one-year follow-up were studied retrospectively. All the subjects had an axial length >26 mm and received a 1 + PRN (pro re nata) regimen IVA or IVR. Best-corrected visual acuity (BCVA) and central macular thicknesses (CMT) on optical coherence tomography were evaluated before and after treatment.

Results

There were 12 eyes in IVA group, with a mean age of 60.0 ± 10.2 years. The mean BCVA significantly improved from baseline 1.54 ± 0.76 to 0.85 ± 0.61 and the mean CMT significantly decreased from baseline 384.3 ± 119.1 μm to 305.9 ± 75.4 μm to 305.9 ± 75.4 p : 0.024 and p : 0.024 and μm to 305.9 ± 75.4 μm to 305.9 ± 75.4 p : 0.024 and p : 0.024 and p : 0.024 and p : 0.024 and.

Conclusions

Both IVA and IVR treatment modalities resulted in similar anatomical outcomes but IVA had better visual outcomes in treatment of mCNV.

Anterior and Posterior Segment Manifestations of Pathological Myopia: A Clinical Study from Turkish Aegean Region

Background and Objective:

Myopia is one of the most prevalent vision conditions caused by a mismatch between the refractive power and axial length of the eyeball. High myopia may have a degenerative disorder, including cornea, sclera, choroid, optic disc, vitreous, macula, and peripheral retina. Although there are few studies regarding clinical features of pathological myopia, especially in the far-eastern countries where myopia is common, but are no comprehensive data in our region. This study was aimed to demonstrate both anterior and posterior ocular segment manifestations of pathological myopia.

Methods:

One hundred forty eyes of 82 patients who met the pathological myopia criteria were enrolled in this prospective study. Measurements of Central Corneal Thickness (CCT), endothelial cell parameters, Anterior Chamber Depth (ACD), Axial Length (AL) and Subfoveal Choroidal Thickness (SFCT) were performed in all patients. Presence of posterior segment pathologies such as peripapillary atrophy, tilted disc, Lacquer's crack, foveoschisis, myopic maculopathy, Choroidal Neovascularization (CNV), and peripheral retinal degeneration was recorded.

Results:

The mean age was 54.1 ± 14.2 years. 43 (52.4%) of the patients were female. One hundred patients (71.4%) were phakic and 40 (28.6%) were pseudophakic. The mean CCT, corneal endothelial cell density, ACD, AL, and SFCT were 548.91 ± 43.44 µm, 2335.89 ± 374.38 cells/mm2, 3.93 ± 0.79 mm, 28.75 ± 2.20 mm, and 94.56 ± 73.11 µm, respectively. Tilted disc, peripapillary atrophy and posterior staphyloma were detected in 89 (63.6%), 119 (85%) and 78 (55.7%) eyes, respectively. Normal fundus, tessellated fundus, diffuse chorioretinal atrophy, focal chorioretinal atrophy and macular atrophy were seen in 13 (9.3%), 59 (42%), 26 (18.6%), 14 (10%), and 28 (20%) eyes, respectively. Lacquer crack, CNV, and Fuchs spot were observed in 11 (7.9%), 39 (27.9%), and 47 (33.6%) eyes, respectively.

Conclusion:

This study reported clinical characteristics of eyes with pathological myopia in a retina specialty clinic at a tertiary referral center from the Turkish Aegean Region. Pathological myopia may affect both anterior and posterior ocular segments. However, posterior segment manifestations may be associated with lesions that threaten vision. Therefore, periodic follow-up in patients with pathological myopia is critical.

Comparison of Individual Retinal Layer Thicknesses between Highly Myopic Eyes and Normal Control Eyes Using Retinal Layer Segmentation Analysis

The incidence of myopia is increasing worldwide, and the investigation on pathophysiology of myopia is becoming more important. This retrospective study aimed to compare the thicknesses of individual retinal layers between high-myopic and control eyes, and to evaluate the effects of age and sex on each retinal layer thickness. We assessed 164 subjects and divided them into two groups based on axial length (AL) (i.e., high-myopic group (AL ≥ 26 mm) and control group (AL < 26 mm)). Individual retinal layer thicknesses of five subfields in the macula were measured using automated retinal segmentation software packaged with the spectral-domain optical coherence tomography and were compared. In high-myopia group, the thicknesses of total retina and all individual retinal layers in central and entire perifoveal subfields were significantly thicker than the corresponding layers in control group after adjustment for ocular magnification (all P < 0.05). There were no significant effects of sex on individual retinal thicknesses, and age had less negative effects on the thicknesses of retina layers in high-myopic eyes than normal eyes. Axially elongated, non-pathologic highly myopic eyes had different structural features than control eyes, with significantly greater individual macular layer thicknesses independent of sex or age.

Myopia Outcome Study of Atropine in Children (MOSAIC): an investigator-led, double-masked, placebo-controlled, randomised clinical trial protocol

Background: The Myopia Outcome Study of Atropine in Children (MOSAIC) aims to explore the efficacy, safety, acceptability and mechanisms of action of 0.01% unpreserved atropine for myopia control in a European population. Methods: MOSAIC is an investigator-led, double-masked, placebo-controlled, randomised clinical trial (RCT) investigating the efficacy, safety and mechanisms of action of 0.01% atropine for managing progression of myopia. During Phase 1 of the trial, 250 children aged 6-16 years with progressive myopia instil eye drops once nightly in both eyes from randomisation to month 24. From month 24 to 36  participants are re-randomised in Phase 2 of the trial, into continued 0.01% atropine, and washout, at 1:1 ratio for those participants initially randomised to the intervention arm (n=167), during which any potential rebound effects on cessation of treatment will be monitored. All participants initially assigned to the placebo (n=83) crossover to the intervention arm of the study for Phase 2, and from month 24 to 36, instil 0.01% atropine eye drops in both eyes once nightly. Further treatment and monitoring beyond 36 months is planned (Phase 3) and will be designed dependent on the outcomes of Phase 1. Results: The primary outcome measure is cycloplegic spherical equivalent refractive error progression at 24 months. Secondary outcome measures include axial length change as well as the rebound, safety and acceptability profile of 0.01% atropine. Additional analyses will include the mechanisms of action of 0.01% atropine for myopia control. Conclusions: The generalisability of results from previous clinical trials investigating atropine for myopia control is limited by the predominantly Asian ethnicity of previous study populations. MOSAIC is the first RCT to explore the efficacy, safety and mechanisms of action of unpreserved 0.01% atropine in a predominantly White population.

Visual Acuity in Pathological Myopia Is Correlated With the Photoreceptor Myoid and Ellipsoid Zone Thickness and Affected by Choroid Thickness

Purpose

To quantify the thickness of the outer retinal sublayers and choroid in pathological myopia and examine associations between these factors and best-corrected visual acuity (BCVA).

Methods

The cohort was composed of 21 eyes with emmetropia and 70 eyes with high myopia (49 simple high myopia; 21 pathological myopia). Optical coherence tomography images were segmented to determine macular thicknesses of the choroid and the following outer retinal sublayers: outer plexiform layer (OPL), Henle fiber layer and outer nuclear layer (HFL + ONL), myoid and ellipsoid zone (MEZ), outer segment of photoreceptors (OS), and interdigitation zone and RPE/Bruch complex (IZ + RPE). Correlations between BCVA and thickness of the outer retinal sublayers and choroid were determined.

Results

In pathological myopia, the choroid, HFL + ONL, MEZ, and IZ + RPE were thinner than in emmetropia and simple high myopia (P < 0.05). Simple and multiple regression models showed that MEZ thickness was correlated with BCVA (both P < 0.001). The relationship between MEZ thickness and BCVA varied with choroidal thickness (P = 0.006). For a constant MEZ thickness, thinner choroids were associated with worse vision. In the final multiple regression predictive model, MEZ thickness, choroidal thickness, and interaction between MEZ and choroidal thickness (all P < 0.001) were predictors of BCVA.

Conclusions

Outer retinal alterations, especially thinning of the MEZ, occurred in pathological myopia. The MEZ thickness was associated with BCVA, and this relationship was affected by choroidal thickness.

Posterior Scleral Reinforcement to Prevent Progression of High Myopia

BACKGROUND

Myopia has become a global public health problem. High myopia is linked to pathologic myopia (PM). As the severity of myopia increases, excessive axial elongation of the globe exerts a biomechanical stretch on the posterior pole, followed by a series of retinopathy which can lead to marked visual impairment. Posterior scleral reinforcement (PSR) is the only way that may have the potential to prevent the progression of axial elongation. Some scholars expressed satisfaction with the efficacy and safety of PSR. In contrast, other surgeons had negative conclusions on the outcomes for the surgery.

OBJECTIVES

The aims of this review are to provide an update on the current knowledge of posterior scleral reinforcement to prevent progression of high myopia and to discuss clinical trials examining the potential utility of PSR in treating this disease.

METHODS

We searched Ovid MEDLINE, Embase, PubMed and China National Knowledge Infrastructure (CNKI) (all years to 1 July 2019). We also conducted a gray literature search and handsearched reference lists of included studies and pertinent review articles.

RESULTS

26 clinical trials were included. 20 trials were designed as only one eye of each patient had posterior scleral reinforcement surgery. After 3 to 5 years of follow-up, the results are very satisfactory. 6 randomized controlled trials, which have conservatively treated groups, showed statistically significant differences between the eyeball axial length progression in the study group and the control group, where surgery was not performed. Most clinical trials reached a positive influence. But the efficacy of different clinical trials varies greatly.

CONCLUSIONS

PSR, is safe and effective to slowdown myopia progression, especially for high myopia.

Regional changes in the elastic properties of myopic Guinea pig sclera

Biomechanical changes in the sclera likely underlie the excessive eye elongation of axial myopia. We studied the biomechanical characteristics of myopic sclera at the microscopic level using scanning acoustic microscopy (SAM) with 7-μm in-plane resolution. Guinea pigs underwent form-deprivation (FD) in one eye from 4 to 12 days of age to induce myopia, and 12-μm-thick scleral cryosections were scanned using a custom-made SAM. Two-dimensional maps of the bulk modulus (K) and mass density (ρ) were derived from the SAM data using a frequency-domain approach. We assessed the effect on K and ρ exerted by: 1) level of induced myopia, 2) region (superior, inferior, nasal or temporal) and 3) eccentricity from the nerve using univariate and multivariate regression analyses. Induced myopia ranged between -3D and -9.3D (Mean intraocular difference of -6.2 ± 1.7D, N = 11). K decreased by 0.036 GPa for every 1.0 D increase in induced myopia across vertical sections (p < 0.001). Among induced myopia right eyes, K values in the inherently more myopic superior region were 0.088 GPa less than the inferior region (p = 0.002) and K in the proximal nasal region containing the central axis were 0.10 GPa less than temporal K (p = 0.036). K also increased 0.12 GPa for every 1 mm increase in superior vertical distance (p < 0.001), an effect that was blunted after 1 week of FD. Overall, trends for ρ were less apparent than for K. ρ values increased by 20.7 mg/cm3 for every 1.00 D increase in induced myopia across horizontal sections (p < 0.001), and were greatest in the region containing the central posterior pole. ρ values in the inherently more myopic superior region were 13.1 mg/cm3 greater than that found in inferior regions among control eyes (p = 0.002), and increased by 11.2 mg/cm3 for every 1 mm increase in vertical distance (p = 0.001). This peripheral increase in ρ was blunted after 1 week of FD. Scleral material properties vary depending on the location in the sclera and the level of induced myopia. Bulk modulus was most reduced in the most myopic regions (both induced myopia and inherent regional myopia), and suggests that FD causes microscopic local decreases in sclera stiffness, while scleral mass density was most increased in the most myopic regions.

Retinal Vasculature and Microstructure in Early Dry-Type Myopic Maculopathy

Purpose

The aim of this cross-sectional study was to characterize and compare the retinal vasculature and microstructure in patients with early dry-type myopic maculopathy.

Methods

Patients with a refractive error of less than -6 diopters were enrolled and classified into two groups. Group 1 comprised 82 eyes with a tessellated fundus, and group 2 comprised 56 eyes with diffuse chorioretinal atrophy (DCA). The clinical characteristics, refractive error, axial length, retinal vessel density of the superficial capillary plexus (SCP) and deep capillary plexus (DCP), macular choroidal thickness, and best-corrected visual acuity (BCVA), were compared between the groups. Logistic regression was used to determine the protective and risk factors for DCA.

Results

Group 1 patients were significantly younger and had better BCVA, less myopia, and shorter axial length than group 2 patients. The vessel densities of the SCP and DCP, choroidal thickness, retinal nerve fiber layer thickness, ganglion cell complex thickness, and retinal thickness were reduced in group 2. Multiple logistic regression analysis revealed that the vessel densities of the SCP and DCP were protective factors for DCA.

Conclusions

The vessel density of the SCP had the highest diagnostic value (sensitivity = 78.0% and specificity = 96.6%). When the SCP vessel density was reduced to ≤49.98%, DCA was indicated. The retinal vessel densities of the SCP and DCP and parameters of the microstructure were reduced significantly in patients with DCA. Vessel density may be a better diagnostic indicator of the development of DCA.

Progression of Myopic Maculopathy in Highly Myopic Chinese Eyes

Purpose

To evaluate the 2-year changes in myopic maculopathy and its associations in highly myopic eyes.

Methods

This was a longitudinal, observational cohort study involving 657 Chinese participants with bilateral high myopia (≤ -6.00 diopters spherical power), who were followed for 2 years. The worst eye of each participant was considered for the analysis. Myopic maculopathy was graded based on fundus photographs, using the International Photographic Classification and Grading System for Myopic Maculopathy.

Results

The mean baseline age was 21.6 ± 12.2 years (range, 6.8-69.7 years). Myopic maculopathy progressed in 97 (14.8%) of 657 eyes, of which 24 eyes progressed to a higher category of myopic maculopathy, including from no maculopathy to tessellated fundus in 17 eyes, from tessellated fundus to diffuse atrophy in 6 eyes, and from diffuse to patchy atrophy in 1 eye. Among 122 lesion changes identified, the most common changes were enlargement of diffuse atrophy (n = 50, 41.0%), appearance of lacquer cracks (n = 28, 23.0%), enlargement of patchy atrophy (n = 10, 8.2%) and development of additional lacquer cracks (n = 7, 5.8%). In addition, we identified 1 eye with enlargement of a Fuch's spot, and 1 eye with active choroidal neovascularization. In multiple logistic regression analysis, myopic maculopathy progression was associated with older age, longer axial length, greater change in myopic spherical equivalent and more severe myopic maculopathy at baseline.

Conclusions

Myopic maculopathy progressed in approximately 15% of highly myopic eyes over a 2-year period. Further studies with longer follow up periods are required to confirm identified risk factors for progression.

IMI - Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies

Purpose

We provide a standardized set of terminology, definitions, and thresholds of myopia and its main ocular complications.

Methods

Critical review of current terminology and choice of myopia thresholds was done to ensure that the proposed standards are appropriate for clinical research purposes, relevant to the underlying biology of myopia, acceptable to researchers in the field, and useful for developing health policy.

Results

We recommend that the many descriptive terms of myopia be consolidated into the following descriptive categories: myopia, secondary myopia, axial myopia, and refractive myopia. To provide a framework for research into myopia prevention, the condition of “pre-myopia” is defined. As a quantitative trait, we recommend that myopia be divided into myopia (i.e., all myopia), low myopia, and high myopia. The current consensus threshold value for myopia is a spherical equivalent refractive error ≤ −0.50 diopters (D), but this carries significant risks of classification bias. The current consensus threshold value for high myopia is a spherical equivalent refractive error ≤ −6.00 D. “Pathologic myopia” is proposed as the categorical term for the adverse, structural complications of myopia. A clinical classification is proposed to encompass the scope of such structural complications.

Conclusions

Standardized definitions and consistent choice of thresholds are essential elements of evidence-based medicine. It is hoped that these proposals, or derivations from them, will facilitate rigorous, evidence-based approaches to the study and management of myopia.

Influence of myopic macular degeneration severity on treatment outcomes with intravitreal aflibercept in the MYRROR study

PURPOSE

To determine the influence of baseline myopic macular degeneration (MMD) severity on outcomes with intravitreal aflibercept (IVT-AFL) in patients with myopic choroidal neovascularization (CNV).

METHODS

MYRROR was a randomized, double-masked study in patients with myopic CNV treated with IVT-AFL/sham over 48 weeks. At baseline/week 48, images were retrospectively graded for MMD.

RESULTS

At baseline, 115 eyes had a valid MMD grading result; at week 48, grading results were available for 99 eyes [IVT-AFL (n = 78)/sham (n = 21)]. Severity of baseline MMD was distributed as follows: category 1: 19/115 (17%); category 2: 67/115 (58%); category 3: 22/115 (19%); category 4: 7/115 (6%). Higher MMD category was associated with older age (nominal p = 0.007) and longer axial length (nominal p = 0.025). At week 48, patients in the mild and severe groups had visual acuity gains of +13.5 and +12.4 letters, respectively. Baseline MMD severity did not significantly affect visual/anatomical outcomes or number of treatments. Visual Functioning Questionnaire-25 scores improved more in mild (+5.6) versus severe (+0.4) MMD (nominal p = 0.03). There were no new safety events.

CONCLUSIONS

Visual acuity gains, morphological outcomes and dosing frequency were not affected by baseline MMD severity in patients treated with IVT-AFL. A benefit with IVT-AFL treatment was observed for all baseline MMD stages included in this study.

Myopia Outcome Study of Atropine in Children (MOSAIC): an investigator-led, double-masked, placebo-controlled, randomised clinical trial protocol

Background: The Myopia Outcome Study of Atropine in Children (MOSAIC) aims to explore the efficacy, safety, acceptability and mechanisms of action of 0.01% unpreserved atropine for myopia control in a European population.

Methods: MOSAIC is an investigator-led, double-masked, placebo-controlled, randomised clinical trial (RCT) investigating the efficacy, safety and mechanisms of action of 0.01% atropine for managing progression of myopia. During Phase 1 of the trial, 250 children aged 6-16 years with progressive myopia instil eye drops once nightly in both eyes from randomisation to month 24. No treatment is given during Phase 2 from month 24 to 36 (washout period) for those participants initially randomised to the intervention arm (n=167), during which any potential rebound effects on cessation of treatment will be monitored. All participants initially assigned to the placebo (n=83) crossover to the intervention arm of the study for Phase 2, and from month 24 to 36, instil 0.01% atropine eye drops in both eyes once nightly. Further treatment and monitoring beyond 36 months is planned (Phase 3) and will be designed dependent on the outcomes of Phase 1.

Results: The primary outcome measure is cycloplegic spherical equivalent refractive error progression at 24 months. Secondary outcome measures include axial length change as well as the rebound, safety and acceptability profile of 0.01% atropine. Additional analyses will include the mechanisms of action of 0.01% atropine for myopia control.

Conclusions: The generalisability of results from previous clinical trials investigating atropine for myopia control is limited by the predominantly Asian ethnicity of previous study populations. MOSAIC is the first RCT to explore the efficacy, safety and mechanisms of action of unpreserved 0.01% atropine in a predominantly White population.

Trial registration: ISRCTN: ISRCTN36732601 (04/10/2017), EudraCTdatabase 2016-003340-37 (03/07/2018).

Distribution and Severity of Myopic Maculopathy Among Highly Myopic Eyes

Purpose

The purpose of this study was to document the distribution of the severity of myopic maculopathy in a cohort of highly myopic patients and to explore the associated risk factors.

Methods

A total of 890 Chinese highly myopes aged between 7 and 70 years (median age 19 years) and with spherical refraction -6.00 diopter (D) or worse in both eyes were investigated. All participants underwent detailed ophthalmic examination. Myopic maculopathy was graded into 5 categories according to the International Photographic Classification and Grading System using color fundus photographs: category 0, no myopic retinal lesions, category 1, tessellated fundus only; category 2, diffuse chorioretinal atrophy; category 3, patchy chorioretinal atrophy; category 4, macular atrophy. Category 2 or greater were further classified as clinically significant myopic maculopathy (CSMM).

Results

Data from 884 of 890 right eyes were available for analysis. The proportions of category 1, category 2, category 3, and category 4 were 20.0% (177 eyes), 20.2% (178 eyes), 2.6% (23 eyes), and 0.2% (2 eyes), respectively. The proportion of CSMM increased with more myopic refraction (odds ratio 1.57; 95% confidence interval: 1.46-1.68), longer axial length (odds ratio 2.97; 95% confidence interval: 2.50-3.53), and older age (40-70 years compared to 12-18 years, odds ratio 6.77; 95% confidence interval: 3.61-12.70). However, there was a higher proportion of CSMM in children aged 7 to 11 years than those aged 12 to 18 years (20.9% vs. 11.0%, P = 0.008).

Conclusions

Older age, more myopic refraction, and longer axial length were associated with more severe myopic maculopathy. Although CSMM was uncommon among younger participants, children with early-onset high myopia have a disproportionately increased risk.

Novel Predictors of Visual Outcome in Anti-VEGF Therapy for Myopic Choroidal Neovascularization Derived Using OCT Angiography

PURPOSE

To explore novel prognostic factors associated with visual function and number of anti-vascular endothelial growth factor (VEGF) treatments in eyes with active myopic choroidal neovascularization (mCNV) using OCT angiography (OCTA).

DESIGN

Prospective case series.

PARTICIPANTS

Twenty-eight treatment-naïve eyes with active mCNV from 27 consecutive patients (mean age, 64.4 ± 11.1 years).

METHODS

All eyes received through injection a single loading dose of intravitreal aflibercept (IVA), followed by additional IVA on a pro re nata (PRN) basis during the subsequent 12 months. At baseline, OCTA images of a 3 × 3-mm macular cube were acquired using an OCTA scanner. On binarized and skeletonized OCTA images of the outer retinal layer, OCTA-derived baseline parameters of mCNV-including lesion size, vessel density, vessel length density (VLD), vessel diameter index, and fractal dimension (FD)-were measured and evaluated for correlation with 12-month best-corrected visual acuity (BCVA) and number of additional injections.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were BCVA 12 months after initial treatment and number of additional injections, respectively.

RESULTS

There was no significant difference between baseline and 12-month BCVA (0.37 ± 0.30 and 0.30 ± 0.35 logarithm of the minimal angle of resolution, respectively; P = 0.23). The number of additional injections was 0.93 ± 1.02 (mean ± standard deviation). Baseline VLD, FD, and BCVA were correlated with 12-month BCVA (P = 0.02, r = 0.46; P = 0.02, r = 0.46; and P = 0.02, r = 0.45, respectively), and VLD also was correlated with the number of additional injections (P = 0.03, r = 0.42).

CONCLUSIONS

Exuberant mCNV, which is characterized by high VLD and FD derived using OCTA, is a predictor of poor visual outcomes after a single IVA injection followed by a PRN regimen. Only baseline VLD was correlated with the number of additional IVA injections, which indicates that this parameter could help to determine the optimal anti-VEGF treatment regimen for individual eyes with mCNV.

Rectus Extraocular Muscle Paths and Staphylomata in High Myopia

PURPOSE

To investigate the relationship between displacement of extraocular muscles (EOMs) and staphyloma in high myopia using magnetic resonance imaging (MRI).

DESIGN

Retrospective case-control study.

METHODS

Setting: Institutional study.

POPULATION

Twenty-nine highly myopic patients (46 eyes), 11 age-matched healthy control subjects (21 eyes), and 34 patients (66 eyes) with sagging eye syndrome.

PROCEDURES

MRI was analyzed for aspect ratio (AR) of the ocular cross section, locations of staphylomata and EOMs, and status of superior rectus to lateral rectus (SR-LR) band ligament.

MAIN OUTCOME MEASURES

Association between staphylomata with EOM paths and the LR-SR band.

RESULTS

Several associations of staphylomata were statistically significant (P < .05). Most staphylomata were superotemporal. Myopic patients with staphyloma had larger ARs in quasi-coronal images than in myopic subjects without staphyloma or normal controls. Compared to patients with high myopia without staphyloma and normal controls, when staphyloma was present, there was more inferior LR displacement, larger LR-globe angle, and larger SR-LR displacement angle than in myopic subjects without staphyloma. Staphyloma in the superotemporal quadrant was associated with greater SR-LR angle than in other quadrants. There were significantly more ruptures of SR-LR band ligament in highly myopic patients with staphyloma than in those without staphyloma.

CONCLUSIONS

Local staphylomata in high myopia reflect ocular asphericity and correlate with EOM paths. Myopic staphylomata are associated with inferior displacement of LR path and defect of the LR-SR band ligament.

Prevalence and Associations of Posterior Segment Manifestations in a Cohort of Egyptian Patients with Pathological Myopia

Purpose: To determine the prevalence of posterior segment manifestations among consecutive patients with pathological myopia attending our University Hospital general ophthalmology clinic and their association with age, refractive error, axial length and each other. Methods: Patients diagnosed with pathological myopia underwent full ophthalmological examination, optical coherence tomography, fluorescein angiography, and ocular ultrasonography. Manifestations detected were recorded for each eye and their prevalence and association with age, refractive error, axial length and each other was determined. Results: A total of 127 eyes of 77 patients with pathological myopia were examined. The most prevalent manifestation was peripheral retinal lesions, found in 63.8% of examined eyes, followed by tigroid fundus, found in 59.1%. Peripheral lesions were significantly associated with more myopia (P = .02) and longer axial length (P = .046). The commonest peripheral lesion was white without pressure, found in 37.8% of eyes. Lattice degeneration was found in 11.8% and snail track degeneration in 4.7% and was not associated with degree of myopia or axial length. Diffuse chorioretinal atrophy was present in 40.9% of eyes, while patchy atrophy was present in 18.9%. Macular holes were present in 4.7% of eyes and were significantly associated with foveoschisis (P = .035) and retinal detachment (P = .003), while foveoschisis was present in 5.5% and was significantly associated with older age (P = .012), longer axial length (P = .010) and patchy chorioretinal atrophy (P = .024). Retinal detachment was found in 6.3% of eyes and retinal breaks in 4.7%. Posterior staphyloma was detected in 33.1% and lacquer cracks and choroidal neovascular membranes in 6.3% of eyes. Conclusions: The prevalence of pathological myopia manifestations may differ between different populations. This may be due to the multiple genetic and environmental factors involved which may result in a variable natural history of the condition among different populations.

Macular retinal thickness and flow density change by optical coherence tomography angiography after posterior scleral reinforcement

Optical coherence tomography angiography (Angio-OCT) has introduced a new non-invasive, quantitative method to assess superficial and deep capillary networks of the retina. In this study, we investigated macular retinal thickness and flow density change following posterior scleral reinforcement (PSR) surgery, using an RTVue XR Avanti Angio-OCT (A2016.2.0.35, Optovue, Fremont, CA), in patients with pathological myopia. A total of 13 patients with pathological myopia were recruited and all patients completed the 6 months follow-up visit. Data from 22 eyes were used in this study. The mean age was 36.23±15.29 years, and 43% (n=6) were men. Spherical equivalent refractive error (SE) ranged from -8.0 to -24.0 D. Post-operative axial length, best-corrected visual acuity and SE did not change significantly at each follow-up, compared with preoperative measure (all P>0.05). Postoperative flow density of superficial and deep retinal layers at each sector did not change significantly at each follow-up, compared to pre-operative measure (all P>0.05). However, we found significant decrease in retinal thickness of parafovea-inferior sector after PSR surgery (P<0.01), indicating potential relaxation of vitreofoveal traction after PSR surgery.

Long-Term Natural Course of Pathologic Myopia in Chinese Patients

PURPOSE

To investigate the natural progression in Chinese patients with pathological myopia (PM) and its associated factors.

METHODS

The medical records of 28 patients with PM (worse than -6 diopter), including 31 eyes of 21 children and 12 eyes of 7 adults, were studied. All of the patients underwent a complete ophthalmologic examination at least twice over 3-year period, including the measurement of refractive error (shown as spherical equivalent, SE), axial length (AL), intraocular pressure, visual acuity (uncorrected visual acuity, UCVA, and best-corrected visual acuity, BCVA), and dilated fundus examination.

RESULTS

The median AL of adults increased significantly from 29.8 mm to 31.43 mm over 5.4 years follow-up (P=0.0037), accompanied with the median SE progressing significantly from -16.4 D to -18.94 D (P=0.0005). Similarly, the median AL of children increased significantly from 26.13 mm to 27.81 mm over 3.9 years (P=0.0001). However, the improvements of UCVA and BCVA in children were significant (P=0.0304, 0.0001), and they had a negative correlation with age (P=0.0010, 0.0005). Also, UCVA and BCVA in children with bilateral PM were significantly better than those with unilateral PM (P=0.0385, 0.0210).

CONCLUSIONS

Fundus degenerations in children with pathological myopia may lead its way since the age of 10 years. Besides, children with bilateral pathological myopia can have parallel development in visual acuity.

Parental attitudes to myopia: a key agent of change for myopia control?

PURPOSE

With the increasing prevalence in myopia there is growing interest in active myopia prevention. This study aims to increase our understanding of parental attitudes to myopia development and control, as a means to inform future health planning and policy. It evaluates, for the first time, the attitude of parents to myopia and its associated risks, as well as assessing the exposure of Irish children to environmental factors that may influence their risk profile for myopia development.

METHODS

Parents of 8-13 year old children in eight participating schools completed a questionnaire designed to assess their knowledge of and attitudes towards myopia and its risk factors. A structured diary was also used to capture daily activities of children in relation to myopia risk factors.

RESULTS

Of 329 parents, just 46% considered that myopia presented a health risk to their children, while an identical number (46%) regarded it as an optical inconvenience. Myopia was also, but less frequently, considered an expense (31% of parents), a cosmetic inconvenience (14% of parents) and, by some, as a sign of intelligence (4% of parents) 76% of parents recognised the potential of digital technology to impact the eye, particularly as a cause of eyestrain and need for spectacles. Only 14% of parents expressed concern should their child be diagnosed with myopia. Compared to non myopic parents, myopic parents viewed myopia as more of an optical inconvenience (p < 0.001), an expense (p < 0.005) and a cosmetic inconvenience (p < 0.001). There was a trend for myopic parents to limit screen time use in their household more than non-myopic parents (p = 0.05). Parents who considered myopia a health risk sought to limit screen time more than parents who did not regard myopia as a health risk to their child (p = 0.01). Children spent significantly longer performing indoor proximal tasks (255 min) compared to time spent outdoors (180 min; p < 0.0001) daily. Older (p = 0.001), urban (p = 0.0005) myopic (=0.04) children spent significantly more time at digital screens compared to younger non-myopic children from a rural background.

CONCLUSION

Parental attitudes to myopia were typically nonchalant in relation to health risk. This is of particular concern given the impact parents have on children's behaviour and choices with respect to such risk factors, demonstrating an acute need for societal sensitisation to the public health importance of myopia.

Five-year incidence and progression of myopic maculopathy in a rural Chinese adult population: the Handan Eye Study

PURPOSE

To determine the cumulative five-year incidence and progression of myopic maculopathy in a rural Chinese adult population.

METHODS

The Handan Eye Study was a population-based longitudinal study. In 2006, 6830 subjects aged 30+ years participated in this study (baseline). Five years later, 5394 subjects (follow-up rate: 85.3%) took part in the follow-up study. Participants had a detailed eye examination, including visual acuity, standardized refraction and fundus photography according to a similar protocol at both baseline and follow-up. Myopic maculopathy was defined as any of the following signs: diffuse chorioretinal atrophy, patchy chorioretinal atrophy, macular atrophy, lacquer cracks and myopic choroidal neovascularization at the posterior pole. Parapapillary atrophy was assessed separately.

RESULTS

Of 5394 participants, 5078 (10 021 eyes) had gradable fundus photographs. Over the five years, four participants (five eyes) developed new myopic maculopathy, with an eye-specific incidence of 0.05% (95% CI, 0.02-0.10%). Among the 51 eyes with myopic maculopathy at baseline, the progression occurred in 18 eyes (35.3%), with new signs of patchy chorioretinal atrophy in 11 eyes (21.6%), diffuse chorioretinal atrophy in seven eyes (13.7%), lacquer cracks in three eyes (6.9%), macular atrophy in three eyes (6.9%) and myopic choroidal neovascularization in two eyes (3.9%). By multivariable analysis, female gender (OR, 9.14; p = 0.004) and higher educational level (OR, 8.24; p = 0.004) were associated with a higher risk of progression of myopic maculopathy, whereas lower myopia at baseline (OR, 0.79; p < 0.0001) and hypertension (OR, 0.21; p = 0.017) were associated with a reduced risk.

CONCLUSIONS

The five-year incidence of myopic maculopathy was 0.05% in rural Chinese adults aged 30+ years. The progression rate in participants with myopic maculopathy was 35.3%, indicating the importance of regular follow-up for these patients.

Myopic maculopathy: Current status and proposal for a new classification and grading system (ATN)

Myopia is a highly frequent ocular disorder worldwide and pathologic myopia is the 4th most common cause of irreversible blindness in developed countries. Pathologic myopia is especially common in East Asian countries. Ocular alterations associated with pathologic myopia, especially those involving the macular area-defined as myopic maculopathy-are the leading causes of vision loss in patients with pathologic myopia. High myopia is defined as the presence of a highly negative refractive error (>-6 to -8 diopters) in the context of eye elongation (26-26.5 mm). Although the terms high myopia and pathologic myopia are often used interchangeably, they do not refer to the same eye disease. The two key factors driving the development of pathologic myopia are: 1) elongation of the axial length and 2) posterior staphyloma. The presence of posterior staphyloma, which is the most common finding in patients with pathologic myopia, is the key differentiating factor between high and pathologic myopia. The occurrence of staphyloma will, in most cases, eventually lead to other conditions such as atrophic, traction, or neovascular maculopathy. Posterior staphyloma is for instance, responsible for the differences between a myopic macular hole (MH)-with and without retinal detachment-and idiopathic MH. Posterior staphyloma typically induces retinal layer splitting, leading to foveoschisis in myopic MH, an important differentiating factor between myopic and emmetropic MH. Myopic maculopathy is a highly complex disease and current classification systems do not fully account for the numerous changes that occur in the macula of these patients. Therefore, a more comprehensive classification system is needed, for several important reasons. First, to more precisely define the disease stage to improve follow-up by enabling clinicians to more accurately monitor changes over time, which is essential given the progressive nature of this condition. Second, unification of the currently-available classification systems would establish standardized classification criteria that could be used to compare the findings from international multicentric studies. Finally, a more comprehensive classification system could help to improve our understanding of the genetic origins of this disease, which is clearly relevant given the interchangeable-but erroneous-use of the terms high and pathologic myopia in genetic research.

The penetration and distribution of topical atropine in animal ocular tissues

PURPOSE

To conduct a multi-tissue investigation on the penetration and distribution of topical atropine in myopia treatment, and determine if atropine is detectable in the untreated contralateral eye after uniocular instillation.

METHODS

Nine mature New Zealand white rabbits were evenly divided into three groups. Each group was killed at 5, 24 and 72 hr, respectively, following uniocular instillation of 0.05 ml of 1% atropine. Tissues were sampled after enucleation: conjunctiva, sclera, cornea, iris, ciliary body, lens, retina, aqueous, and vitreous humors. The assay for atropine was performed using liquid chromatography-mass spectrometry (LC-MS), and molecular tissue distribution was illustrated using matrix-assisted laser desorption ionization-imaging mass spectrometry (MALDI-IMS) via an independent experiment on murine eyes.

RESULTS

At 5 hr, the highest (mean ± SEM) concentration of atropine was detected in the conjunctiva (19.05 ± 5.57 ng/mg, p < 0.05) with a concentration gradient established anteriorly to posteriorly, as supported by MALDI-IMS. At 24 hr, preferential binding of atropine to posterior ocular tissues occurred, demonstrating a reversal of the initial concentration gradient. Atropine has good ocular bioavailability with concentrations of two magnitudes higher than its binding affinity in most tissues at 3 days. Crossing-over of atropine to the untreated eye occurred within 5 hr post-administration.

CONCLUSION

Both transcorneal and transconjunctival-scleral routes are key in atropine absorption. Posterior ocular tissues could be important sites of action by atropine in myopic reduction. In uniocular atropine trials, cross-over effects on the placebo eye should be adjusted to enhance results reliability. Combining the use of LC-MS and MALDI-IMS can be a viable approach in the study of the ocular pharmacokinetics of atropine.

Current concepts of macular buckle in myopic traction maculopathy

Since its introduction by Charles L. Schepens, macular buckle (MB) surgery has evolved over the past 60 years. Optical coherence tomography (OCT) has given a paradigm shift to the understanding of myopic macula, thereby helping in objective evaluation of the various manifestation of traction maculopathy. Staphyloma evaluation by ultrasound, wide-field fundus photography, and MRI scans along with OCT has led to the resurgence of MB surgery in the treatment of myopic traction maculopathy (MTM). Various surgical techniques with different buckle materials are being performed with encouraging anatomical and functional success rates. This article reviews the literature to explain the current concept of MB surgery based on its evolution, different kinds of buckle materials, rationale for planning MB surgery, and different surgical techniques for the management of MTM.

Imaging in myopia: potential biomarkers, current challenges and future developments

Myopia is rapidly increasing in Asia and around the world, while it is recognised that complications from high myopia may cause significant visual impairment. Thus, imaging the myopic eye is important for the diagnosis of sight-threatening complications, monitoring of disease progression and evaluation of treatments. For example, recent advances in high-resolution imaging using optical coherence tomography may delineate early myopic macula pathology, optical coherence tomography angiography may aid early choroidal neovascularisation detection, while multimodal imaging is important for monitoring treatment response. However, imaging the eye with high myopia accurately has its challenges and limitations, which are important for clinicians to understand in order to choose the best imaging modality and interpret the images accurately. In this review, we present the current imaging modalities available from the anterior to posterior segment of the myopic eye, including the optic nerve. We summarise the clinical indications, image interpretation and future developments that may overcome current technological limitations. We also discuss potential biomarkers for myopic progression or development of complications, including basement membrane defects, and choroidal atrophy or choroidal thickness measurements. Finally, we present future developments in the field of myopia imaging, such as photoacoustic imaging and corneal or scleral biomechanics, which may lead to innovative treatment modalities for myopia.

Posterior staphyloma in pathologic myopia

A posterior staphyloma is an outpouching of a circumscribed region of the posterior fundus and has been considered a hallmark of pathologic myopia. Occurring in highly myopic eyes, it is histologically characterized by a relatively abrupt scleral thinning starting at the staphyloma edge, a pronounced de-arrangement of scleral collagen fibrils and a marked choroidal thinning, which is the most marked at the staphyloma edge and which occurs in addition to the axial elongation-associated choroidal thinning. Besides in highly myopic eyes, a posterior staphyloma can be found in non-highly myopic eyes in association with retinitis pigmentosa or localized defects of Bruch's membrane in the cases of which it is not associated with a marked choroidal thinning. The diagnosis of posterior staphylomas is considered best made by wide-field optical coherence tomography, because wide-field optical coherence tomography encompasses the entire extent of the most predominant type of staphylomas (i.e., the wide macular type) and since it also has a sufficiently high resolution of images (in contrast to ultrasonography, computed tomography and three-dimensional magnetic resonance imaging). While the etiology of posterior staphylomas has remained unclear, local choroidal factors and a locally decreased biomechanical resistance of the sclera against a posteriorly expanding Bruch's membrane have been one of the assumed pathogenic parameters. For the therapy of staphylomas, scleral reinforcement strategies such as by posterior encircling bands, posterior scleral collagen cross-linking or scleral regeneration have been discussed or performed, however, with the pathogenesis being elusive, the therapy of staphylomas has remained undetermined.

Diagnosis and Treatment of Myopic Maculopathy

Visual impairment resulting from pathologic myopia is a serious issue worldwide. This is mainly due to the development of different types of myopic maculopathy. Despite being a major cause of visual impairment worldwide, myopic maculopathy was not consistently defined. To overcome this problem, in 2015 the Meta-Analysis for Pathologic Myopia Study Group proposed a simplified, uniform classification system for myopic maculopathy. Among several lesions of myopic maculopathy, myopic choroidal neovascularization (CNV) is one of the most common and severe vision-threatening complications. Recent large clinical trials have reported a good initial efficacy for visual acuity improvement by application of anti-vascular endothelial growth factor therapy for myopic CNVs. However, long-term clinical studies demonstrate a gradual decrease in the visual acuity gain and return to the baseline level due to the development of myopic CNV-related macular atrophy. Regarding visual impairment caused by advanced myopic chorioretinal atrophy, the only way to prevent blindness is to prevent myopia from developing or progressing at a young age before the axial length elongates extremely. As peripapillary diffuse atrophy in childhood may be an indicator of more advanced myopic chorioretinal atrophy in later life, some preventive measures should be considered in such children.

Myopia and orthokeratology for myopia control

The prevalence of myopia in children is increasing worldwide and is viewed as a major public health concern. This increase has driven interest in research into myopia prevention and control in children. Although there is still uncertainty in the risk factors underlying differences in myopia prevalence between ethnic groups, rates in children of East Asian descent are typically higher regardless of where they live. Mounting evidence also suggests that myopia prevalence in children increases with age. Earlier commencement and more rigorous education systems in these countries, resulting in more time spent on near-work activities and less time on outdoor activities, may be responsible for the earlier age of myopia onset. However, to date, the mechanisms regulating myopia onset and progression are still poorly understood. Findings from several studies have shown orthokeratology to be effective in slowing axial elongation and it is a well-accepted treatment, particularly in East Asian regions. While our understanding of this treatment has increased in the last decade, more work is required to answer questions, including: How long should the treatment be continued? Is there a rebound effect? Should the amount of myopia control be increased? To whom and when should the treatment be offered? Practitioners are now faced with the need to carefully guide and advise parents on whether and when to undertake a long somewhat complex intervention, which is costly, both in time and money. In the near future, a greater demand for effective prophylaxis against childhood myopia is envisaged. Other than orthokeratology, atropine therapy has been shown to be effective in slowing myopia progression. While its mechanism of control is also not fully understood, it is likely that it acts via a different mechanism from orthokeratology. Thus, a combined treatment of orthokeratology and atropine may have great potential to maximise the effectiveness of myopia control interventions.

The diluted atropine for inhibition of myopia progression in Korean children

AIM

To evaluate the efficacy and safety of three different concentrations of diluted atropine for the control of myopia in Korean children, and to assess the risk factors associated with rapid myopia progression.

METHODS

A total of 285 children, with refractive errors within the range of -6 diopters (D) between 5 and 14 years of age were included. After using 0.01%, or 0.025%, or 0.05% atropine, for about 1y, changes in refraction, axial lengths and frequency of adverse events were analyzed. Logistic regression analyses were performed to evaluate the risk factors associated with rapid myopia progression.

RESULTS

The changes in the mean spherical equivalent values were -0.134 D/mo in the before atropine group, -0.070 D/mo in the 0.01% atropine group, -0.047 D/mo in the 0.025% atropine group, and -0.019 D/mo in the 0.05% atropine group, with significant differences between the groups (P<0.001). The axial elongation was 0.046 mm/mo, 0.037 mm/mo, 0.025 mm/mo, and 0.019 mm/mo respectively, with significant differences between the groups (P=0.003). The incidence of photophobia and near vision difficulty was not different among the three atropine groups (P=0.425 and P=0.356, respectively). Multivariate logistic regression analyses showed that only highly myopic parents were a significant predictive factor of rapid myopia progression in Korean children (odds ratio, 8.155; 95% confidence interval, 3.626-18.342; P<0.001).

CONCLUSION

Treatment with 0.01%, 0.025% and 0.05% atropine solution inhibits myopia progression in Korean children in a dose-dependent manner. Children with highly myopic parents preferentially shows a rapid myopia progression rate.

Tessellated fundus appearance and its association with myopic refractive error

The appearance of tessellated fundus in an eye may act as a marker in identifying visual performance, degree of myopia or risk of progression of myopia in a given eye. A systematic literature search using key words was performed using PubMed, Web of Science and Google Scholar and of the 832 studies identified, 10 full-length articles, which met the inclusion criteria, were considered for review. The primary outcome measures were association of tessellated fundus with: (i) visual acuity, (ii) refractive error, (iii) axial length, (iv) choroidal thickness and (v) future progression of myopia when compared to either no myopic maculopathy, or more severe myopic maculopathy. There was no significant difference in the visual acuity noted between eyes with normal fundus and tessellated fundus appearance. Compared to eyes with tessellated fundus, eyes with more severe myopic maculopathy had a four-line decrease in best-corrected visual acuity, more myopia (mean difference 2.75 D, range 0.28-5.78 D) and a longer axial length (mean difference 2 mm, range 2.29 to 1.71 mm). Eyes with tessellated fundus generally exhibited a significant decrease in choroidal thickness compared to eyes with no maculopathy. In mostly older individuals, eyes with tessellated fundus had a better outcome with respect to visual acuity, degree of myopia and axial length compared to other severe myopic maculopathies, but had a worse outcome for choroidal thickness and degree of myopia, compared to eyes with no myopic maculopathy. The features such as reduced choroidal thickness combined with a predilection to infra-temporal and parapapillary regions may indicate regions of stress that are prone to more stretching/atrophic changes. This systematic review demonstrated an association of tessellated fundus with visual acuity, refractive error, axial length and choroidal thickness and hence emphasises the documentation of the presence and location of tessellated fundus appearance that may help in predicting the progression of myopia.

Macular Thickness, Foveal Volume, and Choroidal Thickness in Amblyopic Eyes and Their Relationships to the Treatment Outcome

Purpose

To assess the correlations between the retinal/choroidal structure and the treatment outcomes of amblyopic children.

Methods

This study enrolled eyes with amblyopia resulting from strabismus, anisometropia, or ametropia. All patients underwent detailed eye examinations, including spectral domain optical coherence tomography (SD-OCT) scan. All of the subjects received amblyopic treatment and were divided into 2 groups after 6 months of follow-up: the recovered amblyopic group with a best-corrected visual acuity (BCVA) ≥0.8 and the persistent amblyopic group with a BCVA <0.8 on the Landolt C chart.

Results

Forty-four amblyopic children were included, of which 26 were in the recovered amblyopic group after 6 months of follow-up. The patients with strabismic anisometropic amblyopia and severe amblyopia (initial VA ≤ 0.3) were significantly predisposed to developing persistent amblyopia (P=0.049 and P < 0.001, respectively). After correcting with Littmann's formula, the thickness and volume of the parafoveal and perifoveal retinal regions in the persistent amblyopia group did not show significant differences with the recovered amblyopia group.

Conclusions

The initial severity of amblyopia and the type of amblyopia were the risk factors related to the poor outcome of amblyopic treatment. The foveal thickness, foveal volume, and choroidal thickness were not associated with the treatment outcome.

Long-term reproducibility of GC-IPL thickness measurements using spectral domain optical coherence tomography in eyes with high myopia

Although ganglion cell inner plexiform layer (GC-IPL) analysis in the patients with high myopia is useful, there have been few reports to analyze of the reliability for long-term measured GC-IPL thickness. We aimed to analyze the long-term reproducibility of thickness measurements of the GC-IPL using spectral-domain optical coherence tomography (SD-OCT) in patients with high myopia and identify factors that affect such reproducibility. 99 eyes from 99 patients with high myopia without any other ophthalmc disorder such as glaucoma or retinal diseases were included. Two serial SD-OCT (Cirrus-HD) macular scans taken at ≧1 year intervals were analyzed. The intraclass correlation coefficient (ICC), coefficient of variation (CV), and test-retest standard deviation (TRTSD) of GC-IPL thickness measurements were assessed. The ICC, CV, and TRTSD of the mean GC-IPL thicknesses were 0.883, 5.9%, and 2.74, respectively. The ICCs of the six-sector GC-IPL thicknesses ranged from 0.740 to 0.904. The CVs of the minimal and all sectoral GC-IPL thicknesses were <10%. Measurement variances for the mean GC-IPL thicknesses showed significant relationshiups with chorioretinal atrophy and posterior staphyloma. There is high long-term reproducibility in GC-IPL thickness measurements using SD-OCT in high-myopia patients. The factors affecting this reproducibility include chorioretinal atrophy and posterior staphyloma.

EVALUATION OF PATCHY ATROPHY SECONDARY TO HIGH MYOPIA BY SEMIAUTOMATED SOFTWARE FOR FUNDUS AUTOFLUORESCENCE ANALYSIS

PURPOSE

To evaluate the progression of patchy atrophy in high myopia using semiautomated software for fundus autofluorescence (FAF) analysis.

METHODS

The medical records and multimodal imaging of 21 consecutive highly myopic patients with macular chorioretinal patchy atrophy (PA) were retrospectively analyzed. All patients underwent repeated fundus autofluorescence and spectral domain optical coherence tomography over at least 12 months. Color fundus photography was also performed in a subset of patients. Total atrophy area was measured on FAF images using Region Finder semiautomated software embedded in Spectralis (Heidelberg Engineering, Heidelberg, Germany) at baseline and during follow-up visits. Region Finder was compared with manually measured PA on FAF images.

RESULTS

Twenty-two eyes of 21 patients (14 women, 7 men; mean age 62.8 + 13.0 years, range 32-84 years) were included. Mean PA area using Region Finder was 2.77 ± 2.91 SD mm at baseline, 3.12 ± 2.68 mm at Month 6, 3.43 ± 2.68 mm at Month 12, and 3.73 ± 2.74 mm at Month 18 (overall P < 0.005); this accounts for PA progression rate of 0.821 mm/year. Atrophy progression was significantly greater among eyes with larger PA compared with smaller baseline PA at Months 6, 12, and 18. There was no statistically significant difference between semiautomated Region Finder PA area and manually measured PA area on FAF images.

CONCLUSION

Fundus autofluorescence analysis by Region Finder semiautomated software provides accurate measurements of lesion area and allows us to quantify the progression of PA in high myopia. In our series, PA enlarged significantly over at least 12 months, and its progression seemed to be related to the lesion size at baseline.

Design and Baseline Characteristics of the HELP Study: An Extended and Long-Term Observation of Pathological Myopia in Caucasians

PURPOSE

To assess the natural disease progression of high myopia in Caucasians considered at risk for the development of myopic choroidal neovascularization (mCNV).

METHODS

Subjects were recruited in 25 clinical sites between June 2014 and June 2016. Main inclusion criteria included axial length of ≥26 mm, best-corrected visual acuity ≥0.05 decimal equivalent and presence of at least one out of five predefined morphological disease risk criteria. These were (1) subfoveal choroidal thinning < 50 µm, (2) enhanced choroidal curvature length > 6,300 µm, (3) lacquer cracks, (4) patchy atrophy > 5 mm2 and (5) preexisting mCNV in the fellow eye (German Clinical Trial Register DRKS00007761).

RESULTS

A total of 150 participants (66% females) with a mean age of 57.2 (±12.7) years (range 21.9-86.2 years) were included. The disease criteria most frequently encountered were choroidal thinning (33.3%) and lacquer cracks (32.7%). Enhanced choroidal curvature length was detected in only 8 subjects and always occurred in combination with other disease criteria. Presence of patchy atrophy was found to be more common in older subjects (p = 0.0012) and also associated with a more severe disease manifestation.

CONCLUSION

The baseline data of this study indicate that enhanced choroidal curvature might be less common in Caucasians than in Asian populations. Further, disease severity in patients with high myopia is relatively high in the presence of patchy atrophy.

Correlations between the optic nerve head morphology and ocular biometrics in highly myopic eyes

AIM

To analyze peripapillary atrophy β/γ zone (PPA-β/γ) and the optic disc ovality index, and to assess their associations with the axial length (AL), refractive error, best corrected visual acuity (BCVA), choroidal thickness (CT), and age in highly myopic eyes.

METHODS

This was a retrospective observational case series. The study included 667 patients consecutively examined for highly myopic eyes [spherical equivalent ≤-6.0 diopters (D) and AL≥26 mm] with or without myopic retinopathy. Each patient went through a comprehensive ophthalmological examination that included spectral domain optical coherence tomography (SD-OCT) of the macula, A-mode ultrasonography, and a cycloplegic refraction test. The ovality index and PPA-β/γ area were measured from optic disc photographs.

RESULTS

A significant association was seen between PPA-β/γ area and the ovality index (P=0.000, r=-0.232). The PPA-β/γ area increased significantly with a longer AL, older age, worse BCVA, higher refractive error, and thinner choroid (P<0.01). The oval disc was significantly correlated with a longer AL, older age, worse BCVA, higher refractive error, larger PPA-β/γ area, and thinner choroid (P<0.01).

CONCLUSION

The PPA-β/γ zone and ovality index in highly myopic eyes show distinct associations with the AL, refractive error, BCVA, age, and CT.