Macular Bruch Membrane Holes in Highly Myopic Patchy Chorioretinal Atrophy

Bruch's Membrane Opening Changes in Eyes With Myopic Macular Degeneration: AIER-SERI Adult High Myopia Study

Purpose

The purpose of this study was to assess the choroidal thickness and the Bruch's membrane opening size and their relationship to visual acuity in eyes with myopic macular degeneration (MMD).

Methods

This was a population-based, cross-sectional study. Patients over the age of 30 years with high myopia (spherical equivalent ≤-5 diopters [D]) were recruited. The eyes were grouped according to the International Meta-Analysis for Pathologic Myopia (META-PM) classification based on fundus photographs and diffuse atrophy was subdivided into peripapillary diffuse choroidal atrophy (PDCA) or macular diffuse choroidal atrophy (MDCA). Swept-source optical coherence tomography imaging was performed and then the subfoveal choroidal thickness (SFCT) and Bruch's membrane opening diameter (BMOD) were measured.

Results

Of the 470 study participants recruited, 373 patients (691 eyes), with a mean age of 42.8 ± 7.2 years, were eligible for the study and included in the analysis. There was no significant difference in SFCT between MDCA and patchy atrophy (M3) groups (P = 1.000), and the BMOD enlarged significantly from no myopic macular lesions to M3 (the P values of multiple comparison tests were all <0.005). Simple linear regression analysis showed that BMOD correlated positively with age (P < 0.001) and axial length (P < 0.001). Multiple linear regression analysis showed that best corrected visual acuity (BCVA) was significantly correlated with age (P = 0.041), axial length (P = 0.001), and BMOD (P = 0.017), but not with SFCT (P = 0.231).

Conclusions

The significant variation of BMOD among MMD groups and the correlation between BMOD and BCVA in MMD eyes suggest that BMOD may be an imaging biomarker for monitoring MMD.

Myopic Macular Atrophy in the Two-Continent Population-Based Study

Purpose

To examine the prevalence of Bruch's membrane defects (BMDs) and subretinal proliferations (SRPs) in highly myopic eyes with myopic macular atrophy (myopic macular degeneration [MMD] stage 4) and myopic patchy atrophies (MMD stage 3) in three ethnically different cohorts recruited in a population-based manner.

Methods

The Ural Eye and Medical Study (UEMS) and Beijing Eye Study (BES) included individuals aged 40+ years, and the Ural Very Old Study (UVOS) examined individuals aged 85+ years. Main outcome measures were the prevalence of BMDs and SRPs.

Results

Among 5794 UEMS participants, 19 eyes had MMD stage 4, with 17 (89%) eyes showing a foveal BMD; two eyes could not fully be explored. All 19 eyes showed localized SRPs. Among 21 eyes with MMD stage 3, BMD and SRP prevalence was 9 of 21 (44%) and 7 of 21 (33%), respectively. Among 930 UVOS participants, 17 eyes had MMD stage 4, with 16 (94%) eyes showing foveal BMDs and SRPs; one eye could not be assessed. Among 18 eyes with MMD stage 3, BMD and SRP prevalence was 3 of 18 (17%) and 2 of 18 (11%), respectively. Among 3468 BES participants, 8 eyes had MMD stage 4, with all eyes showing foveal BMDs and SRPs. Among 14 eyes with MMD stage 3, BMD and SRP prevalence was 10 of 14 (71%) and 7 of 21 (33%), respectively.

Conclusions

All eyes with assessable myopic macular atrophy showed foveal BMDs associated with SRPs, while patchy atrophies could be differentiated into those with BMDs and SRPs and those without BMDs and without SRPs. Independent of the MMD stage, the prevalences of BMDs and SRPs were highly significantly associated with each other.

LONGITUDINAL CHANGES OF POSTERIOR VORTEX VEINS IN HIGHLY MYOPIC EYES DETERMINED BY RETROSPECTIVE ANALYSES OF INDOCYANINE GREEN ANGIOGRAMS

PURPOSE

To assess the longitudinal changes of the posterior vortex veins (VVs) in highly myopic (HM) eyes.

METHODS

The medical records of 1,730 consecutive HM eyes that had undergone indocyanine green angiography were studied. Eyes that had posterior VVs and had undergone at least two indocyanine green angiography examinations with a minimum interval of 3 years were selected from this group.

RESULTS

Ninety-one eyes of 78 patients met the inclusion criteria. A total of 124 posterior VVs were identified. Over an average interval of 7.8 ± 5.0 years, 41 (33.1%) of the 124 posterior VVs had marked changes consisting mainly of an attenuation of vessels in 36 posterior VVs (87.8%) and alterations in the drainage course in 16 posterior VVs (39.0%). Fifteen posterior VVs had both types of changes. Most of the attenuations of the vessels occurred for smaller branches, but a complete loss of the entire trunk was seen in three eyes. Additionally, four eyes had posterior VV changes in association with changes of peripheral VVs.

CONCLUSION

Posterior VV in highly myopic eyes can undergo changes with increasing time. The associated factors included the development and progression of myopic maculopathy lesions. In some cases, the blood drainage shifted from posterior VV to peripheral VV by forming anastomotic channels.

MACULAR CHORIORETINAL ATROPHY AND VISUAL OUTCOMES IN RANIBIZUMAB- OR AFLIBERCEPT-TREATED MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To investigate the predictors of macular chorioretinal atrophy, consisting of patchy atrophy (PA) at the macula and choroidal neovascularization (CNV)-related macular atrophy (CNV-MA), during treatment with ranibizumab or aflibercept for myopic CNV (mCNV) and its impact on visual outcomes.

METHODS

This retrospective study included 82 eyes with treatment-naïve mCNV who were treated with pro re nata injections of ranibizumab or aflibercept.

RESULTS

Nine eyes (11.0%) presented with macular PA at baseline (PA group), and 73 eyes (89.0%) did not (non-PA group). VA improved during the first year in the non-PA group; a similar trend was noted in the PA group until 3 months after initial treatment. This improvement was maintained until 24 months ( P < 0.001) in the non-PA group, but not in the PA group. In the PA group, macular chorioretinal atrophy progressed faster ( P < 0.0001), and CNV-MA was more frequent during the 2 years of treatments ( P = 0.04). Even non-PA group eyes sometimes developed CNV-MA (42% at Month 24) if they had a larger CNV and thinner subfoveal choroidal thickness at baseline, resulting in poorer visual prognosis ( P < 0.01).

CONCLUSION

Macular PA at baseline was a risk factor for CNV-MA development and was associated with poor visual outcomes.

Using a combination of peripapillary atrophy area and choroidal thickness for the prediction of different types of myopic maculopathy

PURPOSE

To analyse the topographic characteristics in macular choroidal thickness (mChT) and ocular biometry in myopic maculopathy and to explore the potential cut-off value for prediction of myopic maculopathy (MM).

METHODS

All participants underwent detailed ocular examinations. MM was subdivided into thin choroid, Bruch's membrane (BM) defects, choroidal neovascularization (CNV), and myopic tractional maculopathy (MTM) according to OCT-based classification system. Peripapillary atrophy area (PPA), tilt ratio, torsion, and mChT were individually measured.

RESULTS

A total of 1947 participants were included. In multivariate logistics models, older age, longer axial length, larger PPA area, and thinner average mChT were more likely to have MM and different type of MM. Female participants were more likely to have MM and BM defects. A lower tilt ratio was more likely to be associated with CNV and MTM. The area under the curve (AUC) of single tilt ratio, PPA area, torsion, and topographic of mChT for MM, thin choroid, BM Defects, CNV, and MTM were 0.6581 to 0.9423, 0.6564 to 0.9335, 0.6120 to 0.9554, 0.5734 to 0.9312, 0.6415 to 0.9382, respectively. After combining PPA area and average mChT for predicting MM, thin choroid, BM defects, CNV, and MTM, the AUC of the combination were 0.9678, 0.9279, 0.9531, 0.9213, 0.9317, respectively.

CONCLUSION

Progressive and continuous PPA area expanding and thin choroid play a role in the development of myopic maculopathy. The present study showed that a combination of peripapillary atrophy area and the choroidal thickness could be used to predict MM and each type of MM.

Myopia: Histology, clinical features, and potential implications for the etiology of axial elongation

Myopic axial elongation is associated with various non-pathological changes. These include a decrease in photoreceptor cell and retinal pigment epithelium (RPE) cell density and retinal layer thickness, mainly in the retro-equatorial to equatorial regions; choroidal and scleral thinning pronounced at the posterior pole and least marked at the ora serrata; and a shift in Bruch's membrane opening (BMO) occurring in moderately myopic eyes and typically in the temporal/inferior direction. The BMO shift leads to an overhang of Bruch's membrane (BM) into the nasal intrapapillary compartment and BM absence in the temporal region (i.e., parapapillary gamma zone), optic disc ovalization due to shortening of the ophthalmoscopically visible horizontal disc diameter, fovea-optic disc distance elongation, reduction in angle kappa, and straightening/stretching of the papillomacular retinal blood vessels and retinal nerve fibers. Highly myopic eyes additionally show an enlargement of all layers of the optic nerve canal, elongation and thinning of the lamina cribrosa, peripapillary scleral flange (i.e., parapapillary delta zone) and peripapillary choroidal border tissue, and development of circular parapapillary beta, gamma, and delta zone. Pathological features of high myopia include development of macular linear RPE defects (lacquer cracks), which widen to round RPE defects (patchy atrophies) with central BM defects, macular neovascularization, myopic macular retinoschisis, and glaucomatous/glaucoma-like and non-glaucomatous optic neuropathy. BM thickness is unrelated to axial length. Including the change in eye shape from a sphere in emmetropia to a prolate (rotational) ellipsoid in myopia, the features may be explained by a primary BM enlargement in the retro-equatorial/equatorial region leading to axial elongation.

Anatomic Peculiarities Associated with Axial Elongation of the Myopic Eye

PURPOSE

To describe anatomical peculiarities associated with axial elongation in the human myopic eye.

METHODS

Reviewing the results of previous histomorphometrical investigations of enucleated human globes, as well as reviewing findings obtained in population-based studies and hospital-based clinical investigations of myopic patients and non-myopic individuals.

RESULTS

Myopic axial elongation is associated with a change from a mostly spherical eye shape to a prolate ellipsoid form. It is combined with choroidal and scleral thinning, most pronounced at the posterior pole and less pronounced in the fundus midperiphery. In the fundus midperiphery, the retina and density of the retinal pigment epithelium (RPE) and photoreceptors decrease with a longer axial length, while in the macular region, retinal thickness, RPE cell density, and choriocapillaris thickness are not related to axial length. With axial elongation, a parapapillary gamma zone develops, leading to an enlargement of the optic disc-fovea distance and a decrease in angle kappa. Axial elongation is also correlated with an increase in the surface and volume of Bruch's membrane (BM), while BM thickness remains unchanged. Axial elongation causes moderately myopic eyes to show a shift of BM opening to the foveal direction so that the horizontal disc diameter becomes shorter (with a consequent vertical ovalization of the optic disc shape), a temporal gamma zone develops, and the optic nerve exit takes an oblique course. Features of high myopia are an enlargement of the RPE opening (myopic parapapillary beta zone) and BM opening (secondary macrodisc), elongation and thinning of the lamina cribrosa, peripapillary scleral flange (parapapillary delta zone) and peripapillary choroidal border tissue, secondary BM defects in the macular region, myopic maculoschisis, macular neovascularization, and cobblestones in the fundus periphery.

CONCLUSIONS

These features combined may be explained by a growth in BM in the fundus midperiphery leading to axial elongation.

Myopic macular Bruch's membrane defects

Purpose

To examine histologic characteristics of macular Bruchś membrane defects (BMD) in axially elongated eyes.

Design

Histomorphometric study.

Methods

Using light microscopy, we examined enucleated human globes for BMDs.

Results

In 247 eyes, BMDs were detected in 15 (6.1%) eyes (axial length:27.0-36.0 mm), in 10 of them in the macular region. Prevalence and size of BMDs (mean:1.93 ± 1.62 mm; range:0.22mm-6.24 mm) correlated with longer axial length (OR:1.52; 95%CI:1.19,1.94; P = 0.001) and higher prevalence of scleral staphylomas (OR:16.3; 95%CI:2.67,99.3; P < 0.001). The BMDs were smaller than corresponding gaps in the retinal pigment epithelium (RPE) (1.93 ± 1.62 mm versus 2.61 mm ± 1.73 mm; P = 0.003), and larger than corresponding gaps in the inner nuclear layer (0.43 ± 0.76 mm; P = 0.008) and inner limiting membrane bridges (0.13 ± 0.33 mm; P = 0.001). Choriocapillaris thickness, BM thickness and RPE cell density did not vary (all P > 0.05) between the BDM border and adjacent areas. In the BMD, choriocapillaris and RPE were absent. The sclera was thinner in the BDM area than in adjacent areas (0.28 ± 0.19 mm versus 0.36 ± 0.13 mm; P = 0.006).

Conclusions

BMDs as hallmarks of myopic macular degeneration are characterized by longer gaps in the RPE and smaller gaps in the outer nuclear layer and inner nuclear layer, by localized scleral thinning, and by a spatial association with scleral staphylomas. Thickness of the choriocapillaris and density of the RPE cell layer, both absent within the BDMs, do not vary between the BMD border and adjacent regions. The results suggest an association between BDMs and absolute scotomas, stretching of the adjacent retinal nerve fiver layer, and an axial elongation-associated stretching effect on BM as etiology of the BDMs.

Time-Serial Evaluation of the Development and Treatment of Myopia in Mice Eyes Using OCT and ZEMAX

Myopia is a significant cause of visual impairment which may lead to many complications. However, the understanding of the mechanisms of myopia is still limited. In this paper, in order to investigate the development and the treatment of myopia, we analyzed the biological structure parameters of mice eyes, obtained from optical coherence tomography (OCT), and the optical performance of mice eyes calculated using ZEMAX software (ZEMAX Development Corporation, Kirkland, WA, USA) in which the optical model was built on the segment-by-segment optically corrected OCT 3D-images. Time-serial evaluation of three groups of mice eyes (form-deprivation myopia mice eyes, normal mice eyes, and atropine-treated myopia mice eyes) was performed. In addition to the biological structure parameters, imaging performance with the development of root-mean-square wavefront aberration at six filed angles was compared and analyzed. Results show that the biological structure parameters of the eye are closely related to the development of myopia. The peripheral defocus of the retina has a significant impact on inducing myopia, which verifies the new theory of myopia development. The delaying effect of atropine solution on myopia development is shown to verify the therapeutic effect of the medicine. This study provides technical support for the investigation of the myopia mechanism.

Association of Retinal Sensitivity With Optical Coherence Tomography Microstructure in Highly Myopic Patients

Purpose

To investigate the association of retinal sensitivity with microstructural features in optical coherence tomography (OCT) of high myopic eyes.

Methods

This cross-sectional study included 78 eyes (78 patients). Microstructural features on spectral-domain OCT, such as the integrity of the retinal pigment epithelium (RPE), ellipsoid zone (EZ), and external limiting membrane (ELM) and outer retinoschisis, were evaluated at each retinal location corresponding to microperimetric testing points.

Results

For all testing points, retinal sensitivity was significantly associated with the integrity of the RPE, EZ, and ELM (all P < 0.001) based on OCT but not with outer retinoschisis (P = 0.183). A higher category of myopic maculopathy according to the Meta-Analysis of Pathologic Myopia classification was associated with lower mean retinal sensitivity (P < 0.001). In eyes with patchy atrophy (PA), mean retinal sensitivity of testing points adjacent to the PA lesion (15.7 ± 6.8 dB) was greater than points within or at the PA border (2.6 ± 5.2 dB; P < 0.001) but lower than distant points (19.6 ± 4.3 dB; P < 0.001). Microstructural features in OCT were well correlated with the differences in retinal sensitivity according to myopic maculopathy severity and proximity to the PA lesion.

Conclusions

In highly myopic eyes, retinal sensitivity on microperimetry was strongly associated with microstructural features in OCT. Both retinal sensitivity and microstructure were affected by the severity of myopic degeneration and proximity to the PA lesion.

Distribution and association of visual impairment with myopic maculopathy across age groups among highly myopic eyes - based on the new classification system (ATN)

Purpose

To investigate the percentages and risk factors for visual impairment (VI) across age groups in a highly myopic cohort with a wide range of age (18–93 years).

Methods

A total of 2099 eyes (1220 participants) were enrolled. All participants underwent detailed ocular examinations. Myopic maculopathy (MM) was assessed as myopic atrophy maculopathy (MAM), myopic traction maculopathy (MTM) or myopic neovascular maculopathy (MNM) based on the ATN system.

Results

Most participants younger than 50 years had normal vision, while the cumulative risk of VI and blindness gradually increased after 50–59 years. The percentage of each type of MM increased nonlinearly with ageing (all p < 0.001), with an accelerated period of increase after 45 years for MAM, and after 50 years for MTM and MNM. Axial length (AL) ≥30 mm was the only associated factor for mild VI or worse in participants aged 18–39 years (p < 0.001). Older age, AL ≥30 mm and the presence of MAM were predictors for mild VI or worse in the group aged 40–49 years (all p < 0.05). In participants aged ≥50 years, older age, female sex, longer AL and increased severity of MM were risk factors for VI and blindness (all p < 0.05).

Conclusion

The percentages of MM and related VI increased nonlinearly with older age, with a turning point at 45 years for MAM, preceding that of MTM, MNM and VI by 5 years, warranting future longitudinal studies to confirm. Different age groups presented different risk factors for VI. Timely screening should be in place for middle‐aged high myopes.

PREVALENCE AND CHARACTERISTICS OF MULTIFOCAL CHOROIDITIS/PUNCTATE INNER CHOROIDOPATHY IN PATHOLOGIC MYOPIA EYES WITH PATCHY ATROPHY

PURPOSE

To determine the prevalence and characteristics of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) in eyes with patchy atrophy because of pathologic myopia.

METHODS

Five hundred eyes of 253 patients with patchy atrophy were examined between 2014 and 2020 at the Advanced Clinical Center for Myopia. The main outcome measures included the prevalence and characteristics of active MFC/PIC lesions diagnosed by optical coherence tomography.

RESULTS

Fifty-five of the 500 eyes (11%) diagnosed with patchy atrophy had optical coherence tomography features of active MFC/PIC lesions, such as focal elevations of the retinal pigment epithelium filled with medium hyperreflectivity material, curvilinear scars (Schlaegel lines), and/or areas of outer retinal atrophy. At the time when the MFC/PIC was diagnosed, the mean age was 57.3 ± 12.0 years, and the mean axial length was 29.2 ± 1.8 mm. Macular neovascularization was found in 45 of eyes (81.8%) with MFC/PIC versus 151 eyes without such findings (33.9%; P < 0.001). In 25 of the 55 eyes (45.5%), active MFC/PIC lesions were found before the development of the patchy atrophy. The Bruch membrane defects were colocated with these lesions.

CONCLUSION

Active MFC/PIC lesions were identified in a minority of eyes with pathologic myopia, and a subset of these lesions were observed to progress to findings indistinguishable from myopic patchy atrophy. Evidence of MFC/PIC in eyes with pathologic myopia appeared to be a risk factor for the development of macular neovascularization.

Discerning Between Macular Hemorrhages Due to Macular Neovascularization or Due to Spontaneous Bruch’s Membrane Rupture in High Myopia: A Comparative Analysis Between OCTA and Fluorescein Angiography

Introduction

To evaluate the sensitivity and specificity of optical coherence tomography angiography (OCTA) in comparison to fluorescein angiography (FA) in discerning between macular hemorrhages due to myopic macular neovascularization (m-MNV) and idiopathic macular hemorrhage (IMH) in patients with high myopia (HM).

Methods

In this retrospective study, 14 eyes of 14 patients (mean age 60 ± 16 years) affected by macular hemorrhage due to HM were included. All patients underwent OCTA and FA at the time of macular hemorrhage (i.e., baseline) and were followed for a 3-month follow-up.

Results

By means of FA, 8 out of 14 eyes with macular hemorrhage (57%) were diagnosed as type 2 m-MNV, whereas 6 eyes (43%) were diagnosed as IMH. Interestingly, OCTA displayed the presence of a neovascular network in all cases previously diagnosed as m-MNV using FA, and also excluded the presence of anomalous flow in all IMH eyes. This accounted for the high sensitivity and specificity of OCTA for m-MNV detection in HM cases with macular hemorrhage. After 3-month follow-up, BCVA improved from 0.39 ± 0.15 to 0.21 ± 0.14 logMAR (p = 0.006) in patients with m-MNV treated by a mean of 2.3 ± 0.9 intravitreal anti-VEGF injections. Conversely, BCVA improved without treatment (from 0.55 ± 0.48 to 0.17 ± 0.08 logMAR, p = 0.112) in patients with IMH.

Conclusions

OCTA is able to differentiate with excellent reliability between the presence of m-MNV in patients with HM presenting with a new macular hemorrhage and an IMH. This could be of paramount relevance in the clinical setting for the diagnosis and treatment of patients with HM.

Sympathetic ophthalmia in eye with pathologic myopia

PURPOSE

To present our findings in a case of SO that developed in an eye with pathologic myopia.

OBSERVATIONS

The patient was an 83-year-old woman who was examined one month after an ocular trauma to the right eye. She was found to have signs of uveitis with multiple serous retinal detachments in the non-injured contralateral left eye. In addition, she had hearing loss and mononuclear pleocytosis of the spinal fluids. Swept-source OCT images showed focal and choroidal thickening in areas with abrupt edges that was restricted to the regions with more normal appearing choroid. Bruch's membrane was damaged at the edge of the focal choroidal thickening. The ocular and systemic findings were rapidly resolved after systemic corticosteroid therapy.

CONCLUSIONS AND IMPORTANCE

The pathobiological and clinical course of SO is nearly identical to Vogt-Koyanagi Harada disease (VKH) although its pathogenesis of autoimmunity had not been definitively established. In eyes with pathologic myopia, the choroid is extremely thin and sometimes completely absent. The findings in this rare case indicate that in eyes with thin choroid, the OCT findings typical of SO might be different from those seen in non-highly myopic eyes. Thus, the pre-status of the choroid may affect the choroidal thickening in pathological conditions. This case gives us a valuable insight in understanding the pathology of SO and characteristic of pathologic myopia.

Choroidal Thickness and Its Association With Age, Axial Length, and Refractive Error in Chinese Adults

Purpose

To identify the association between the choroidal thickness (ChT) with age and axial length (AL) under different refractive errors (REs) in Chinese adults.

Methods

Swept-source optical coherence tomography was used to measure ChT in 2126 right eyes of 2126 participants. The participants were classified as having pathologic myopia (PM), high myopia without PM (HM), low myopia (LM), and nonmyopia (non-M) according to their REs and META-PM (the Meta-Analysis of Pathologic Myopia) classification criteria.

Results

The mean age was 52.49 ± 20.39 years (range, 18−93 years), and the mean RE was −5.27 ± 5.37 diopters (D; range, −25.5 to +7.75 D). The mean average ChT was 159.25 ± 80.75 µm and decreased in a linear relationship from non-M to PM (190.04 ± 72.64 µm to 60.99 ± 37.58 µm, P < 0.001). A significant decline in ChT was noted between 50 and 70 years (r = −0.302, P < 0.001) and less rapidly after the age of 70 years (r = −0.105, P = 0.024). No correlation was noted between age and ChT under 50 years (P = 0.260). A significantly higher association with AL was noted in the central fovea (β^HM = −23.92, β^LM = −23.88, β^Non-M = −18.80, all P < 0.001) and parafoveal ChT (β^HM = −22.87, β^LM = −22.31, β^Non-M = −18.61, all P < 0.001) when compared with the perifoveal region (β^HM = −19.80, β^LM = −18.29, β^Non-M = −13.95, all P < 0.001). Within each group of PM, HM, LM, and non-M, regression analysis showed that the coefficients of age and AL with different macular regions of ChT varied significantly.

Conclusions

ChT was negatively correlated with age after 50 years. The thinning of the choroid was more prominent in the center and parafoveal regions as AL increased. Varied distributions of ChT decrease associated with AL and age were noted among different refractive groups.

Rapid progression of chorioretinal atrophy in punctate inner choroiditis: a case report

Background

The chorioretinal inflammatory lesions occurring in punctate inner choroiditis evolve into punched-out atrophic scars. Typically, the progression is gradual. We report a case of highly myopic punctate inner choroiditis with rapid progression of chorioretinal atrophy.

Case presentation

A 48-year-old Japanese woman with high myopia presented with decreased visual acuity. Best-corrected visual acuity was 20/28 in the right eye and 20/16 in the left eye; axial length was 29.0 mm and 28.7 mm, respectively. Fundoscopy revealed an epiretinal membrane in the left eye. Three years later, the best-corrected visual acuity in the left eye had decreased to 20/33; at this time, the patient underwent vitrectomy with epiretinal membrane and internal limiting membrane peeling in this eye. Six months later, the best-corrected visual acuity in the left eye decreased suddenly to 20/100. Optical coherence tomography showed a nodule-like lesion in the outer retina with disruption of the retinal pigment epithelium and a focally thickened choroid, compatible with PIC. One month later, the choroidal thickness had decreased. The central chorioretinal atrophy expanded rapidly at a rate of 0.45 mm²/year over the next 3 years, and new areas of patchy focal chorioretinal atrophy developed in the perifovea.

Conclusions

Rapid progression of chorioretinal atrophy was observed in a patient with punctate inner choroiditis. Because punctate inner choroiditis is often associated with degenerative myopia, the retina is fragile and may be susceptible to mechanical damage. This case report alerts clinicians to the need for careful management of patients with punctate inner choroiditis, especially after vitrectomy.

Automatic Screening and Identifying Myopic Maculopathy on Optical Coherence Tomography Images Using Deep Learning

Purpose

The purpose of this study was to engineer deep learning (DL) models that can identify myopic maculopathy in patients with high myopia based on optical coherence tomography (OCT) images.

Methods

An artificial intelligence (AI) system was developed using 2342 qualified OCT macular images from 1041 patients with pathologic myopia admitted to the Affiliated Eye Hospital of Wenzhou Medical University (WMU). We adopted an ResNeSt101 architecture to train five independent models to identify the following five myopic maculopathies: macular choroidal thinning, macular Bruch membrane (BM) defects, subretinal hyper-reflective material (SHRM), myopic traction maculopathy (MTM), and dome-shaped macula (DSM). We tested the models with an independent test dataset that included 450 images obtained from 297 patients with high myopia. Focal loss was used to address class imbalance, and optimal operating thresholds were determined according to the Youden Index. The performance was quantified using the area under the receiver operating characteristic (AUC), sensitivity, specificity, and confusion matrix.

Results

For the identification of myopic maculopathy, the AUCs of receiver operating characteristic (ROC) curves were 0.927 to 0.974 for 5 myopic maculopathies. Our AI system achieved sensitivities equal to or even better than those of junior retinal specialists (56.16–99.73%). The diagnosis of it is also interpretable that we provide visual explanations clearly via heatmaps.

Conclusions

We developed a convolutional neural network (CNN)-based DL AI system for detection and classification of myopic maculopathy in patients with high myopia using OCT macular images. Our AI system achieved sensitivities equal to or even better than those of junior retinal specialists.

Translational Relevance

This AI system can be widely applied in sophisticated situations in large-scale high myopia screening.

ABRUPTLY EMERGING VESSELS IN EYES WITH MYOPIC PATCHY CHORIORETINAL ATROPHY

PURPOSE

To determine the prevalence and characteristics of abruptly emerging vessels (AEVs) within patchy atrophy (PA) in myopic eyes.

METHODS

We studied 160 highly myopic eyes of 144 patients between March and November in 2016. Fundus photographs and swept-source optical coherence tomography images were analyzed.

RESULTS

Patient mean age was 67.1 ± 10.5 years. Mean axial length was 30.9 ± 2.0 mm. The mean size of the 264 PAs was 5.6 ± 8.3 mm. Abruptly emerging vessels were detected in 69 (43.1%) eyes and were located within or near PA edge in fundus photographs. Swept-source optical coherence tomography showed that the AEVs were continuous with perforating scleral vessels and were observed on the inner surface of the sclera at the site where they appeared in fundus photographs. A slight bowing of sclera around the AEVs was observed in 41 (59%) eyes. Patchy atrophy with AEVs was significantly larger (10.7 ± 11.3 mm) than PA without AEVs (3.4 ± 5.1 mm).

CONCLUSION

Abruptly emerging vessels are commonly found in eyes with myopic PA. The sclera surrounding the AEVs is slightly bowed. Further studies are needed to determine whether the penetrating site of AEVs is structurally more fragile and leads to Bruch membrane defects or AEVs are secondarily involved during PA progression.

IMI Pathologic Myopia

Pathologic myopia is a major cause of visual impairment worldwide. Pathologic myopia is distinctly different from high myopia. High myopia is a high degree of myopic refractive error, whereas pathologic myopia is defined by a presence of typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high myopia, however its complications especially posterior staphyloma can also occur in eyes without high myopia.

Owing to a recent advance in ocular imaging, an objective and accurate diagnosis of pathologic myopia has become possible. Especially, optical coherence tomography has revealed novel lesions like dome-shaped macula and myopic traction maculopathy. Wide-field optical coherence tomography has succeeded in visualizing the entire extent of large staphylomas. The effectiveness of new therapies for complications have been shown, such as anti-VEGF therapies for myopic macular neovascularization and vitreoretinal surgery for myopic traction maculopathy.

Myopia, especially childhood myopia, has been increasing rapidly in the world. In parallel with an increase in myopia, the prevalence of high myopia has also been increasing. However, it remains unclear whether or not pathologic myopia will increase in parallel with an increase of myopia itself. In addition, it has remained unclear whether genes responsible for pathologic myopia are the same as those for myopia in general, or whether pathologic myopia is genetically different from other myopia.

Retinal pigment epithelium melanin distribution estimated by polarisation entropy and its association with retinal sensitivity in patients with high myopia

PURPOSE

To investigate retinal sensitivity of highly myopic eyes without choroidal neovascularisation (CNV) or patchy chorioretinal atrophy (PCA) and investigated its association with anatomical characteristics including melanin distribution at the retinal pigment epithelium (RPE), which was evaluated with polarisation-sensitive optical coherence tomography (PS-OCT).

DESIGN

Retrospective consecutive observational cohort study.

METHODS

We included highly myopic eyes (refractive error ≤-8.0 dioptres or axial length of ≥26.5 mm) from patients at the University of Tokyo Hospital. Retinal sensitivity was measured by microperimetry at 25 sectors within 6 degrees from the fovea. Depolarisation value, which reflected melanin pigmentation, was measured by a clinical prototype of PS-OCT and was parameterised as polarimetric entropy. Retinal sensitivity or entropy at the RPE in high myopia was compared with emmetropic control subjects. The association of retinal sensitivity with age, axial length, entropy, or choroidal thickness was assessed in per-eye and per-sector analysis.

RESULTS

Twenty-three highly myopic eyes (age, 66.6±12.3 years) were included. The average retinal sensitivity was 25.3±3.0 dB, which was significantly decreased compared with the control (p<0.0001). The average entropy at the RPE in the highly myopic eyes was significantly lower than in the control (p<0.0001). Univariate analysis followed by multivariate analysis showed that besides age, axial length or choroidal thickness, RPE entropy was independently associated with retinal sensitivity (β=4.4; 95% CI 0.5 to 8.3; p=0.03).

CONCLUSIONS

Decreased depolarisation at the RPE measured with PS-OCT, which reflected altered melanin pigmentation, was independently associated with reduced retinal sensitivity in patients with early stages of myopic maculopathy without CNV or PCA.

CLINICAL FEATURES OF PATCHY CHORIORETINAL ATROPHY IN PATHOLOGIC MYOPIA

PURPOSE

To reveal clinical features of patchy atrophy in pathologic myopia and investigate the status of the Bruch membrane and retinal pigment epithelium by swept-source optical coherence tomography.

METHODS

This study reviewed highly myopic patients who visited the high myopia clinic between January 2015 and February 2018. Wide-field photographs and wide-field fundus autofluorescence fundus images were used as the primary method for identifying PAs, and swept-source optical coherence tomography images were used for investigating the retinochoroid status of PAs.

RESULTS

Four hundred fifty-six PAs were detected in 137 eyes (118 patients). Patchy atrophys were located most often in the macular area (28.3%), followed by the inferior (25.9%), temporal (18.9%), nasal (14.5%), and superior (12.5%) region. All 210, PAs which had been fully or partially scanned by swept-source optical coherence tomography, showed a retinal pigment epithelium defect, and 174 (82.9%) PAs showed a Bruch membrane defect on the available scans. In 101 (82.8%) of 122 PAs with clearly detectable borders of the retinal pigment epithelium and Bruch membrane defect, the Bruch membrane defects were smaller than the retinal pigment epithelium defects. A dome-shape inward bulging of the sclera was observed in 10 PAs.

CONCLUSION

These morphological findings may provide a basis for exploring the biomechanical etiology of the PAs as part of the development of pathologic myopia.

Evolution of Macular Bruch Membrane Defects of Patchy Chorioretinal Atrophy in Pathologic Myopia Based on a Recent Classification System

PURPOSE

The purpose of this study was to analyze the progression of macular Bruch membrane defects (BMD) in highly myopic patients with patchy atrophy (PA); and study its correlation with the enlargement of PA and ATN grading. Setting/Venue: Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain.

PATIENTS AND METHODS

This was a cross-sectional, noninterventional study. A series of 451 highly myopic eyes with spherical equivalent > -6.0 D and/or >26 mm of axial length (AL) were included. All patients underwent a complete ophthalmological examination and swept-source optical coherence tomography (SS-OCT), and were graded using the ATN system by 2 masked retina experts that assessed the atrophic (A), tractional (T), and neovascular (N) components. SS-OCT b-scans were employed to study PA and macular BMD at baseline and at a 1-year follow-up, in patients with good foveal fixation.

RESULTS

Out of total 451 eyes, 126 eyes (27.9%) had PA (53 patients; 75.4% women). Mean T and N in eyes with PA were 1.1 ± 1.3 and 0.08 ± 0.2, respectively. Sixty-eight of them had >1-year follow-up with a good foveal fixation and enough image quality. From them, BMD were found in 44 eyes (64.7%) at baseline and increased to 59 eyes (86.7%) at a 1-year follow-up. The mean great linear dimension of PA and macular BMD increased with a median of 384.5 ± 462.5 μm (IR 68.0-660.2) and 265.6 ± 418.1 μm (IR 0-331.7), respectively. At 1-year, PA and BMD sizes increase, and were statistically significant (p < 0.001). There was a positive correlation between the growth of macular BMD and the growth of PA (r = 0.490, p < 0.00). T grading correlated significantly with PA growth (p < 0.05).

CONCLUSIONS

Macular BMD increase its prevalence and its size over time in highly myopic patients with PA. There is a positive correlation between BMD and PA area growth. New studies with a larger sample size, longer follow-up, and AL elongation correlation are necessary to corroborate our findings.

Review on current concepts of myopia and its control strategies

Myopia poses a significant burden on the healthcare system, economy and quality of life. It is an emerging global public health challenge and requires interventions to delay or stop onset and progression. With changing times and evidence, the concepts of myopia are changing along with the treatment and control strategies. Behavioural modifications including increased outdoors time and reduced near work, optical and pharmaceutical management options are reviewed. This paper presents a current overview on the concepts of myopia, and is expected to summarize updates on myopia control methods.

Choroidal neovascularization secondary to pathological myopia-macular Bruch membrane defects as prognostic factor to anti-VEGF treatment

PURPOSE

To evaluate the prevalence and visual outcomes of macular Bruch membrane (BM) defects in patients treated with anti-vascular endothelial growth factors (VEGF) for choroidal neovascularization secondary to pathological myopia (mCNV).

METHODS

Single-center retrospective observational case series of 68 eyes from 62 patients with mCNV treated with one anti-VEGF injection followed by a pro re nata (1 + PRN) regimen. A minimum follow-up of 6 months was defined. Chorioretinal atrophy was assessed by fundus examination, fluorescein angiography, and SD-OCT.

RESULTS

Median follow-up was 28.5 (range 6-89) months with a median number of 5 anti-VEGF injections. At baseline, 27.9% of eyes had macular BM defects increasing to 36.8% during follow-up (p<0.001). Eyes without macular BM defects at the baseline had higher BCVA at the last observation than patients with BM defects (p=0.003). An increase of 5 or more ETDRS letters was more frequent in eyes without BM defects (p=0.001). At the end of follow-up, mCNV-related macular atrophy was present in 44.1%; out of which, 83.3% presented macular BM defects (p<0.001). Eyes with mCNV-related macular atrophy without BM defects had a significant increase of best-corrected visual acuity compared with eyes with mCNV-related macular atrophy and BM defect (p=0.002).

CONCLUSIONS

Macular Bruch membrane defects are often seen in mCNV and have a significant impact in visual acuity and prognosis. Eyes with macular BM defects have a poorer response and worse visual outcomes after anti-VEGF therapy.

Three-year OCT predictive factors of disease recurrence in eyes with successfully treated myopic choroidal neovascularisation

PURPOSE

To assess the relationship of demographics, clinical characteristics and structural optical coherence tomography (OCT) findings to disease recurrence in a cohort of patients with newly diagnosed myopic choroidal neovascularisation (CNV) METHODS: In this retrospective, longitudinal study, a total of 64 participants (64 eyes) with successfully treated myopic CNV had obtained resolution of exudation after treatment (study baseline) and with 3 years of regular follow-ups. Several baseline OCT qualitative features and quantitative measurements were assessed at baseline and included in the analysis. Main outcome measures included incidence of disease recurrence and HR for demographics, clinical characteristics and OCT risk factors.

RESULTS

At month 36, 40 eyes (62.5%) developed disease recurrence (active CNV). Multivariate linear regression analysis revealed that final visual acuity (dependent variable) was associated with visual acuity at the first visit after complete resolution of exudation (p<0.0001), baseline size of patchy atrophy (p=0.010), baseline subfoveal choroidal thickness (p=0.008), baseline maximum CNV height and width (p=0.011 and p=0.003) and recurrence of CNV exudation (p=0.007). The following factors were associated with an increased risk of disease recurrence: size of patchy atrophy had an HR of 1.14 (95% CI 1.01 to 1.29; p=0.036); maximum CNV width had an HR of 1.02 (95% CI 1.01 to 1.04; p<0.0001).

CONCLUSION

We identified OCT risk factors for the disease recurrence in eyes with successfully treated myopic CNV. Assuming that disease recurrence is a sight-threatening event, our findings may help in the identification of high-risk patients and eventually ameliorate their outcome.

Chorioretinal Atrophy in Punctate Inner Choroidopathy/multifocal Choroiditis: A Five-year Follow-up Study

Purpose: To report the 5-year results of chorioretinal atrophy (CRA) progression in patients with punctate inner choroidopathy (PIC) or multifocal choroiditis (MFC).Methods: A retrospective study included PIC/MFC patients with secondary CRA formation. The area of CRA was measured and the progression rate was calculated. Multiple regression analysis was performed to investigate risk factors associated with CRA progression.Results: Forty-five eyes of 36 patients were included. The mean CRA size significantly increased after an average of 4.83 years of follow-up with progression rate of 0.69 mm²/year. Moreover, we had identified the axial length and initial PIC lesion number as significant risk factors for CRA progression.Conclusion: Significant CRA enlargement is noted in PIC/MFC patients after 5 years of follow-up. The progression rate is associated with axial length and initial PIC numbers. Aggressive treatment is suggested for eyes with more initial lesion numbers and longer axial length to control the faster CRA progression.

Macular irregularities of optical coherence tomographic vertical cross sectional images in school age children

The purpose of this study was to compare the incidences of macular irregularities of elementary school (ES) and junior high school (JHS) students. This was a prospective cross-sectional observational study of 122 right eyes of 122 ES students (8-9 years) and 173 right eyes of 173 JHS students (12-13 years). Vertical cross-sectional images of the macula were obtained by optical coherence tomography. The eyes were classified based on the vertical symmetry of the posterior pole, and then sub-classified as convex-, flat-, concave-, or dome-shaped based on the direction of the curvature of the retinal pigment epithelium. One hundred and two eyes (83.6%) were placed in the symmetrical group in the ES students and 149 eyes (86.1%) in the JHS students. Twenty eyes (16.4%) were placed in the asymmetric groups in the ES students and 24 eyes (13.9%) in the JHS students. In symmetrical group, 78 and 118 eyes had a convex-shape (76.4 and 79.2%), followed by 22 and 29 eyes of dome-shaped group (21.6 and 19.4%) in ES and JHS students respectively. Because the incidences of the posterior pole shapes were not significantly different between the groups, it is likely that the macular irregularities develop before the age of ES.

Clinical Characteristics of Highly Myopic Patients With Asymmetric Myopic Atrophic Maculopathy-Analysis Using Multimodal Imaging

Purpose

To evaluate the factors associated with asymmetric myopic atrophic maculopathy (MAM) in highly myopic patients.

Methods

We enrolled highly myopic patients with asymmetric MAM according to the atrophy, traction, and neovascularization (ATN) classification. The results of color fundus photography, optical coherence tomography (OCT), OCT angiography, and corneal visualization Scheimpflug technology (Corvis ST tonometry) were reviewed. The association between inter-eye differences in clinical features and MAM grading was analyzed using logistic regression analysis.

Results

Among the 72 eyes of 36 patients 61.0 ± 9.3 years of age, 9, 33, 17, and 13 eyes had A1, A2, A3, and A4, respectively. The mean axial length was 30.44 ± 1.92 mm, and there was no significant difference between eyes with less severe and more severe MAM. The inter-eye differences in MAM grading were associated with the inter-eye differences in the presence of Bruch's membrane defects (P = 0.014), ellipsoid zone disruption (P = 0.013), vessel density of the deep retinal layer (P = 0.022), foveal avascular zone circularity (P = 0.012), foveal avascular zone area (P = 0.049), flow area of the choriocapillaris (P = 0.013), vessel diameter (P = 0.045), and fractal dimension (P = 0.015). No Corvis ST parameter was statistically significant. A higher difference in the choriocapillaris flow area (P = 0.013; adjusted odds ratio = 1.10 [1.02–1.18]) remained associated with higher inter-eye differences in MAM grading in the multivariable regression.

Conclusions

A smaller choriocapillaris flow area was associated with more severe MAM, suggesting that vascular factors play pivotal roles in MAM.

Retinal applications of swept source optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA)

The advent of optical coherence tomography (OCT) revolutionized both clinical assessment and research of vitreoretinal conditions. Since then, extraordinary advances have been made in this imaging technology, including the relatively recent development of swept-source OCT (SS-OCT). SS-OCT enables a fast scan rate and utilizes a tunable swept laser, thus enabling the incorporation of longer wavelengths than conventional spectral-domain devices. These features enable imaging of larger areas with reduced motion artifact, and a better visualization of the choroidal vasculature, respectively. Building on the principles of OCT, swept-source OCT has also been applied to OCT angiography (SS-OCTA), thus enabling a non-invasive in depth-resolved imaging of the retinal and choroidal microvasculature. Despite their advantages, the widespread use of SS-OCT and SS-OCTA remains relatively limited. In this review, we summarize the technical details, advantages and limitations of SS-OCT and SS-OCTA, with a particular emphasis on their relevance for the study of retinal conditions. Additionally, we comprehensively review relevant studies performed to date to the study of retinal health and disease, and highlight current gaps in knowledge and opportunities to take advantage of swept source technology to improve our current understanding of many medical and surgical chorioretinal conditions. We anticipate that SS-OCT and SS-OCTA will continue to evolve rapidly, contributing to a paradigm shift to more widespread adoption of new imaging technology to clinical practice.

Morphological differences between two types of Bruch's membrane defects in pathologic myopia

PURPOSE

To investigate morphological differences between two types of Bruch's membrane (BM) defects-patchy atrophy (PA) and CNV-related macular atrophy (CNV-MA) METHODS: Eyes presenting with PA or CNV-MA were included. Scleral thickness (ST), choroidal thickness (CT), and scleral morphological characteristics were obtained by swept-source optical coherence tomography (SS-OCT). Fundus photographs were performed to measure the size of PA and CNV-MA lesions.

RESULTS

Among a total of 167 eyes evaluated, 106 eyes had PA and 61 eyes had CNV-MA. In addition, dome-shaped macula (DSM) was identified in 20 (18.87%) and 10 (16.39%) eyes among PA and CNV-MA, respectively. The eyes of CNV-MA without DSM showed a thicker subfoveal ST (278.61 ± 56.17 vs 231.58 ± 66.09 mm, P < 0.001), a thinner subfoveal CT, and a higher rate of scleral perforating vessels (70.6% vs 50.0%, P = 0.021) when compared with those of PA without DSM. The size of PA/CNV-MA lesions was associated with CT in eyes without DSM. However, it was only associated with bulge height in eyes with DSM (r = 0.5, P = 0.013).

CONCLUSIONS

The eyes with CNV-MA had a thicker sclera than those with PA, which add another evidence to indicate the absence of the progressive relationship between two types of BM defects. The enlargement of lesions in BM defects between eyes with and without DSM may be caused by different mechanical forces. SS-OCT, which focuses on scleral and choroid morphology, may be necessary for more accurate classification of pathologic myopia.

Patchy Scotoma Observed in Chorioretinal Patchy Atrophy of Myopic Macular Degeneration

Purpose

To investigate the retinal sensitivity of highly myopic eyes with chorioretinal patchy atrophy (PA) using microperimetry.

Methods

Fifty-two eyes of 32 patients with high myopia were prospectively included. Twenty-two eyes of 16 patients had PA lesions; eyes without PA were analyzed as controls. Testing points on microperimetry in eyes with PA were designated as 3 zones: zone 1 as the PA lesion including its borders; zone 2 including testing points adjoining PA; zone 3 including all other testing points.

Results

In the PA group, the mean retinal sensitivity in zone 1 was 2.1 ± 2.8 dB, zone 2 = 8.3 ± 4.3 dB, and zone 3 = 9.4 ± 4.1 dB. Sensitivity in zone 1 was significantly reduced than zones 2 and 3 (P < 0.001). The mean retinal sensitivity in the PA group was lower than controls (6.5 ± 4.3 vs 13.9 ± 4.1 dB, P < 0.001), and combined zone 2 and 3 in the PA group also presented lower retinal sensitivity (8.8 ± 4.0 dB).

Conclusions

Eyes with PA generate patchy scotoma in PA lesions and reduced retinal sensitivity in regions beyond atrophic lesion on microperimetry. The presence of PA may be an indicator to reflect both significantly anatomical and functional alterations on myopic macular degeneration.

Posterior segment conditions associated with myopia and high myopia

Myopia, and especially high myopia, is associated with a number of posterior segment changes that are considered to be mostly a consequence of the increased axial elongation. This can result in mechanical strain, attendant vascular changes, stretching and thinning of tissues, and atrophy/deformation of tissues in later or more advanced stages. Such myopia-related changes are observed as changes and/or abnormalities in the vitreous, choroid, retina and peripheral retina, sclera and/or optic disc. Although many of these changes are benign, at times they may be associated with significant vision impairment that either requires active intervention or may suggest future progression of the disease. This review systematically addresses the posterior segment conditions seen in myopic eyes, describes the features associated with the condition and details management pathways.

DEVELOPMENT OF MACULAR ATROPHY AFTER PARS PLANA VITRECTOMY FOR MYOPIC TRACTION MACULOPATHY AND MACULAR HOLE RETINAL DETACHMENT IN PATHOLOGIC MYOPIA

PURPOSE

To determine the incidence and long-term outcome of macular atrophy (MA) after pars plana vitrectomy (PPV) in pathologic myopia.

METHODS

Highly myopic patients who underwent PPV for myopic traction maculopathy and macular hole retinal detachment at Tokyo Medical and Dental University between 2012 and 2016 were studied. Fundus photographs and/or optical coherence tomography were examined before and after PPV at every visit.

RESULTS

A total of 133 eyes were followed for 39 months with the mean age of 62.8 years and the mean axial length of 30.0 mm. Postoperatively, 14 eyes (10.5%) developed fovea-centered MA, observed initially as a small, isolated, whitish lesion at the center of fovea at 3.5 months after PPV. The appearance of the MA was distinctly different from the choroidal neovascularization-related MA or patchy atrophy-related MA. With time, the lesions enlarged circumferentially. In these 14 eyes, the final best-corrected visual acuity was worse than the baseline, although the difference was not significant. The occurrence of MA was significantly associated with the preoperative foveal status.

CONCLUSION

The development of MA can occur in 11% of highly myopic eyes after PPV for myopic traction maculopathy and macular hole retinal detachment. This postoperative MA might be a new complication of pathologic myopia.

Myopia: Anatomic Changes and Consequences for Its Etiology

The process of emmetropization is the adjustment of the length of the optical axis to the given optical properties of the cornea and lens after the end of the second year of life. Up to the end of the second year of life, the eye grows spherically. Axial elongation in the process of emmetropization after the second year of life is associated with a thinning of the retina and a reduced density of retinal pigment epithelium (RPE) cells in the equatorial and retroequatorial region, and a thinning of the choroid and sclera, starting at the equator and being most marked at the posterior pole. In contrast, retinal thickness and RPE density in the macular region and thickness of Bruch membrane (BM) in any region are independent of axial length. It led to the hypothesis that axial elongation occurs by the production of additional BM in the equatorial and retroequatorial region leading to a decreased RPE density and retinal thinning in that region and a more tube-like than spherical enlargement of the globe, without compromise in the density of the macular RPE cells and in macular retinal thickness. The increased disc-fovea distance in axially myopic eyes is caused by the development and enlargement of parapapillary, BM-free, gamma zone, whereas the length of macular BM, and indirectly macular RPE cell density, and macular retinal thickness, remain constant.

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.

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.

TEMPORAL VASCULAR ARCADE WIDTH AND ANGLE IN HIGH AXIAL MYOPIA

PURPOSE

Axial myopia is associated with elongation of the posterior ocular segment. The authors measured posterior fundus landmarks and assessed their associations with axial length.

METHODS

Using fundus photographs, the authors measured the vertical distance between the temporal superior and temporal inferior arterial arcade (VDA) and the angle kappa between the temporal arterial arcades among other morphometric variables.

RESULTS

The study included 456 eyes with a mean age of 61.2 ± 14.2 years (range: 13-88 years) and mean axial length of 29.4 ± 2.1 mm (range: 23.2-35.3 mm). Mean angle kappa was 91.3 ± 17.2° (range: 39-161°), and mean VDA was 7.93 ± 1.71 mm (range: 2.72-12.85 mm). In multivariate regression analysis, wider angle kappa was associated (regression coefficient r: 0.47) with shorter axial length (P = 0.002; beta: -0.17; B: -1.37; 95% confidence interval [CI]:-2.23 to -0.51), longer VDA (P < 0.001; beta: 0.27; B: 2.70; 95% CI: 1.85-3.54), shorter disk-foveola distance (P < 0.001; beta: -0.22; B: -4.76; 95% CI: -7.05 to -2.46), shorter vertical optic disk diameter (P = 0.002; beta: -0.14; B: -6.83; 95% CI: -11.1 to -2.56), lower number of any chorioretinal lesions (P = 0.007; beta: -0.13; B: -2.11; 95% CI: -3.63 to -0.58), and longer maximal vertical chorioretinal lesion diameter (P = 0.05; beta: 0.09; B: 0.92; 95% CI: -0.02 to 1.86). A longer VDA was associated (r: 0.31) with longer axial length (P < 0.001; beta: 0.22; B: 0.18; 95% CI: 0.10-0.25), wider angle kappa (P < 0.001; beta: 0.28; B: 0.03; 95% CI: 0.02-0.04) and higher number of chorioretinal lesions (P = 0.03; beta: 0.10; B: 0.16; 95% CI: 0.02-0.31). If eyes with chorioretinal lesions were excluded, the association between longer VDA and longer axial length was no longer statistically significant (P > 0.10).

CONCLUSION

Axial elongation was correlated with decreasing angle kappa, caused by an elongation of the disk-foveola distance because of an enlargement of the gamma zone, whereas VDA remained constant. By contrast, horizontal length of macular Bruch membrane and vertical length of macular Bruch membrane were independent of axial elongation. Axial elongation did not lead to lengthening of Bruch membrane in the macular region in eyes without macular chorioretinal lesions.

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.

Ten-Year Progression of Myopic Maculopathy: The Beijing Eye Study 2001-2011

PURPOSE

To investigate the progression pattern of myopic maculopathy and associated factors in a population-based study.

DESIGN

Population-based longitudinal study.

PARTICIPANTS

The Beijing Eye Study including 4439 participants in 2001 was repeated in 2011, with 2695 individuals (66.4%) being re-examined in 2011.

METHODS

The study participants underwent detailed ophthalmic and general examinations. Using fundus photographs obtained in 2001 and 2011, we assessed the progression of myopic maculopathy in highly myopic eyes with a refractive error ≥-6 diopters in 2001. Myopic maculopathy was differentiated into tessellated fundus (category 1), diffuse chorioretinal atrophy (category 2), patchy chorioretinal atrophy (category 3), and macular atrophy (category 4), with lacquer cracks and choroidal neovascularization as additional plus signs.

MAIN OUTCOME MEASURES

Progression pattern of myopic maculopathy.

RESULTS

Of 110 highly myopic eyes (70 individuals) at baseline, 39 eyes (35.5%) showed progression observed in 15 of 79 eyes (19%) with tessellated fundus at baseline, in 17 of 24 eyes (71%) with diffuse chorioretinal atrophy, in all 6 eyes with patchy chorioretinal atrophy, and the 1 eye with macular atrophy. Lacquer cracks detected in 2 eyes in 2001 developed into a small patchy atrophy (1 eye) or widened during the follow-up (1 eye). Five eyes demonstrated new lacquer cracks. In binary regression analysis, progression of myopic maculopathy was associated with longer axial length (P < 0.001; odds ratio [OR], 7.13; 95% confidence interval [CI], 2.49-20.4), older age (P = 0.001; OR, 1.25; 95% CI, 1.10-1.42), higher prevalence of staphylomas (P = 0.03; OR, 24.3; 95% CI, 2.89-204), smaller parapapillary γ-zone in 2011 (P = 0.01; OR, 0.61; 95% CI, 0.41-0.91), and female gender (P = 0.04; OR, 9.78; 95% CI, 1.06-90.6).

CONCLUSIONS

The 10-year progression rate of myopic maculopathy in this elderly Chinese population was 35.5%, increasing from 15 of 79 eyes (19%) in category 1 of myopic maculopathy at baseline to 17 of 24 eyes (71%) in category 2 and 6 of 6 eyes (100%) in category 3. Risk factors for myopic maculopathy progression were longer axial length, pre-existing staphylomata, smaller parapapillary γ-zone, older age, and female gender.

Corrugated Bruch's membrane in high myopia

PURPOSE

To assess the appearance of Bruch's membrane (BM) in axially elongated eyes.

METHODS

The light-microscopical investigation included histological anterior-posterior sections of human eyes. Using a light microscope, we assessed whether BM in the posterior segment was straight or locally corrugated. Corrugation of BM was defined as an elevation of BM with a height >20 μm over a basis of 50 μm without collateral proliferations of retinal pigment epithelium or choroidal swelling.

RESULTS

The investigation included 85 eyes (age: 62.0 ± 14.1 years; axial length: 26.7 ± 3.5 mm). In multivariate analysis, the presence of a corrugated BM, detected in eight eyes (9.4%), was strongly associated with the presence of macular BM defects [p = 0.001; odds ratio (OR): 418; 95% confidence interval (CI): 1 215 000], but not with axial length (p = 0.54). Bruch's membrane (BM) corrugation was detected in seven (54%) of 13 eyes with macular BM defects. The single eye with BM corrugation and without macular BM defect showed the corrugated BM located in the parapapillary region at the peripheral end of a large parapapillary gamma zone.

CONCLUSION

Bruch's membrane (BM) corrugation can be present in the vicinity of macular BM defects in highly myopic eyes, perhaps due to differences in the tension within BM in various regions at the margin of the BM defect. Bruch's membrane (BM) corrugation may also develop at the papillary end of BM in eyes with a large parapapillary gamma zone, potentially due to a disinsertion of BM at the end of the peripapillary choroidal border tissue of Jacoby. The observation of BM corrugation may help elucidating the aetiology of axial myopia.

FULL-THICKNESS MACULAR HOLE WITH MACULAR INTRACHOROIDAL CAVITATION IN A PATIENT WITH PATHOLOGIC MYOPIA

PURPOSE

To describe a full-thickness macular hole (MH) opening to macular intrachoroidal cavitation in a patient with pathologic myopia.

METHODS

Full ophthalmologic examination, fundus camera (Topcon TRC; Topcon Co, Tokyo, Japan), optical coherence tomography (RetinaScan Advanced RS-3000; NIDEK, Gamagori, Japan) imaging, and cataract surgery.

RESULTS

A 61-year-old woman admitted with decreased vision in the left eye. Visual acuity was counting fingers from 30 cm. Anterior segment examination showed advanced cataract. Fundus examination revealed pathologic myopia. There was full-thickness MH opening to macular intrachoroidal cavitation in contact with the anterior surface of the sclera subfoveally. Except for the communicating part of MH and macular intrachoroidal cavitation, outer retina, ellipsoid zone, and retinal pigment epithelium were intact. Choroid was intact except for a small part at subfoveal area. The patient received an uncomplicated cataract surgery. Visual acuity improved to 5/10. Because she was satisfied, MH surgery was postponed to a later date.

CONCLUSION

Full-thickness MH may occur within the area of macular intrachoroidal cavitation in pathologic myopia.

Progression of Myopic Maculopathy during 18-Year Follow-up

PURPOSE

To examine the progression pattern of myopic maculopathy.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Highly myopic patients who had been followed up for 10 years or more.

METHODS

Using fundus photographs, myopic features were differentiated according to Meta-analysis of Pathologic Myopia (META-PM) Study Group recommendations.

MAIN OUTCOME MEASURES

Progression pattern of maculopathy.

RESULTS

The study included 810 eyes of 432 patients (mean age, 42.3±16.8 years; mean axial length, 28.8±1.9 mm; mean follow-up, 18.7±7.1 years). The progression rate of myopic maculopathy was 47.0 per 1000 eye-years. Within the pathologic myopia (PM) group (n = 521 eyes), progression of myopic maculopathy was associated with female gender (odds ratio [OR], 2.21; P = 0.001), older age (OR, 1.03; P = 0.002), longer axial length (OR, 1.20; P = 0.007), greater axial elongation (OR, 1.45; P = 0.005), and development of parapapillary atrophy (PPA; OR, 3.14; P < 0.001). Diffuse atrophy, found in 217 eyes without choroidal neovascularization (CNV) or lacquer cracks (LCs) at baseline, progressed in 111 (51%) eyes, leading to macular diffuse atrophy (n = 64; 64/111 or 58%), patchy atrophy (n = 59; 53%), myopic CNV (n = 18; 16%), LCs (n = 9; 5%), and patchy-related macular atrophy (n = 3; 3%). Patchy atrophy, detected in 63 eyes without CNV or LCs at baseline, showed progression in 60 eyes (95%), leading to enlargement of original patchy atrophy (n = 59; 59/60 or 98%), new patchy atrophy (n = 29; 48%), CNV-related macular atrophy (n = 13; 22%), and patchy-related macular atrophy (n = 5; 8%). Of 66 eyes with LCs, 43 eyes (65%) showed progression with development of new patchy atrophy (n = 38; 38/43 or 88%) and new LCs (n = 7; 16%). Reduction in best-corrected visual acuity (BCVA) was associated mainly (all P < 0.001) with the development of CNV or CNV-related macular atrophy and enlargement of macular atrophy.

CONCLUSIONS

The most frequent progression patterns were an extension of peripapillary diffuse atrophy to macular diffuse atrophy in diffuse atrophy, enlargement of the original atrophic lesion in patchy atrophy, and development of patchy atrophy in LCs. Main risk factors for progression were older age, longer axial length, and development of PPA.

Peri-dome Choroidal Deepening in Highly Myopic Eyes With Dome-Shaped Maculas

PURPOSE

To determine characteristics of peri-dome choroidal deepening (PDCD) surrounding dome-shaped maculas (DSMs) in highly myopic eyes.

DESIGN

Observational case series.

METHODS

Applying swept-source optical coherence tomography, we examined the posterior pole of highly myopic eyes with DSMs.

RESULTS

The study included 91 highly myopic eyes (67 patients; mean age: 60.0 ± 15.1 years; mean axial length: 30.0 ± 7.4 mm) with a mean dome height of the DSM of 232 ± 132 μm. PDCDs were detected in 53 (58%) eyes. Subfoveal choroidal thickness was significantly thinner in eyes with vs without PDCDs (35 ± 29 μm vs 62 ± 48 μm; P = .016), while both groups did not vary significantly (all P ≥ .25) in age, axial length, and dome height. In contrast to peripapillary intrachoroidal cavitations (ICCs), PDCDs consisted of a widened choroid without large low-reflective suprachoroidal spaces. Unlike peripapillary ICCs or macular ICCs, PDCDs were not associated with caving of the overlying retina or backward bowing of the sclera. In the region of the PDCDs, the Bruch membrane (BM) was shorter than the inner scleral surface. Defects of the BM overlying the PDCDs were detected in 20 (38%) eyes.

CONCLUSIONS

PDCDs were common findings in highly myopic eyes with DSMs. PDCDs may be associated with a dome-induced inward push of the BM at the top of the DSM, leading to a compression of the subfoveal choroid and, owing to an increased strain of the BM on the dome's slopes, to a relative detachment of BM in the peri-dome region.

[Secondary diseases in high myopia]

BACKGROUND

Eyes with high myopia (axial length ≥ 26.5 mm) do not just have a different size. Due to morphological and structural changes there is a considerably increased risk for many different secondary diseases.

OBJECTIVE

Determination of the incidence and mortality in high myopia, discussion of effects and clinical signs, presentation of treatment recommendations and counselling.

MATERIAL AND METHODS

A systematic search of the literature was carried out and a discussion on basic principles and epidemiological investigations is presented.

RESULTS

Findings due to high myopia are not in a closed state but undergo continuous changes. Choroidal neovascularization (adjusted prevalence 2.5-5%), staphyloma, foveoschisis and peripheral retinal degeneration are examples of problems contributing to the increased rate of visual impairment and blindness related to myopia. High myopia is associated with a clearly increased risk of retinal detachment after lens surgery (hazard ratio 6.1) and particularly more frequently in younger people. The associated primary open-angle glaucoma (odds ratio 2.46) is often recognized too late due to relatively low values of intraocular pressure.

CONCLUSION

Understanding of atrophic areas and staphyloma has benefited from recent advances in imaging (e.g. magnetic resonance imaging, optical coherence tomography and wide-field imaging) that complement and explain histological findings. Knowledge of the associated risk profile is of major clinical relevance.

Macular Bruch's membrane defect and dome-shaped macula in high myopia

Purpose

To examine an association between macular Bruch’s membrane defects (MBMD) and a dome-shaped appearance of the macula (DSM).

Design

Retrospective, observational case series study.

Methods

The study included highly myopic individuals who were consecutively examined between May 2014 and December 2015. The patients underwent swept-source optical coherence tomography (OCT) for visualization of DSM and MBMDs defined as Bruch´s membrane defects located at a distance of maximal 1500 μm from the foveola.

Results

Out of 1983 highly myopic eyes (1057 patients), 166 eyes (8.4%; 95% confidence interval (CI):7.2%,9.6%)) showed a DSM and 534 eyes showed a MBMD. In multivariate binary regression analysis, higher prevalence of DSM was associated with a higher prevalence of a MBMD (P<0.001; OR: 1.96; 95%CI: 1.40, 2.75) after adjusting for longer axial length (P<0.001; odds ratio (OR): 1.27; 95%CI: 1.16, 1.38). In eyes with a DSM partially surrounded by a MBMD, the retina, retinal pigment epithelium (RPE) and choroid appeared relatively unchanged in the central region with Bruch´s membrane (BM) preserved. In the ring-like BM-free region surrounding the central prominent island of the DSM, the RPE, the outer and middle retinal layers, the choriocapillaris and the middle-sized choroidal vessel layer were absent. In association with a DSM, three MBMD types were differentiated: MBMDs in patchy chorioretinal atrophy, MBMDs in choroidal neovascularization-related macular atrophy, and MBMDs as temporally extending large parapapillary gamma zone.

Conclusions

Presence of a DSM was significantly associated with the presence of MBMDs. The morphology of the DSM in association with MBMDs may be associated with a focal relaxation of the posterior sclera, no longer pushed outward by an expanding BM but allowed to partially bulge inward, leading to the formation of a DSM.