Myopic Traction Maculopathy: A New Perspective on Classification and Management

Lamellar macular hole in highly myopic eyes and insights into its development, evolution, and treatment: a mini-review

Lamellar macular holes (LMHs) are a manifestation of myopic tractional maculopathy (MTM). Owing to the complex and multidirectional traction force in the elongated eyeball, the clinical features, development, evolution, and treatment algorithms of LMH in highly myopic eyes may differ from those of idiopathic LMH or MTM in general. This review aimed to specifically explore the LMHs in highly myopic eyes. Several developmental processes of LMH and their association with macular retinoschisis have been demonstrated, with the tractional component identified in all processes. Epiretinal proliferation was more prevalent and more extensive in LMHs in highly myopic eyes than in idiopathic LMHs. LMHs in highly myopic eyes may remain stable or progress to foveal detachment and full-thickness macular hole with or without retinal detachment. The predictive factors associated with disease progression were summarized to facilitate monitoring and guide surgical intervention. The treatment of LMHs in highly myopic eyes was based on an algorithm for treating myopic tractional maculopathy, including gas tamponade, pars plana vitrectomy, macular buckling, and a combination of vitrectomy and macular buckling. New internal limiting membrane (ILM) manipulation techniques such as fovea-sparing ILM peeling or fovea-sparing ILM peeling combined with ILM flap insertion could reduce the risk of developing iatrogenic full-thickness macular holes postoperatively. Further research should focus on the treatment of LMH in highly myopic eyes.

EVALUATION OF MACULAR ATROPHY IN PATIENTS TREATED WITH MACULAR BUCKLE FOR MYOPIC TRACTION MACULOPATHY: Mid- and Long-Term Follow-Up

PURPOSE

To evaluate the incidence, rate, and pattern of progression of myopic maculopathy in eyes operated with macular buckle (MB) for myopic traction maculopathy versus a control group without surgery to find out whether the progression varies due to the MB's indentation and to evaluate possible MB-related pigmentary changes or atrophy.

METHODS

Eyes operated with MB with two good quality fundus images: one preoperative or early postoperative image and a second image at least 12 months apart; the control group comprised the contralateral eyes. Demographics, axial length, follow-up, stage of myopic traction maculopathy, and myopic maculopathy were reported. Progression results of groups and subgroups (mid- and long-term follow-up) were reported and compared.

RESULTS

Overall, 116 eyes of 66 patients were included. Progression was found in 29 eyes (41.4%) and 23 eyes (50%) in the MB group and control group, respectively. The progression rate was 73 per 1,000 eye-years and 88.9 per 1,000 eye-years in the MB group and the control group, respectively. Axial length was found to predict progression (odds ratio [OR], 2.59; P = 0.02).

CONCLUSION

Progression of myopic maculopathy was similar in both groups and was mildly greater in the control group. No MB-related pigmentary changes or atrophy was detected.

Characteristics and Prognostic Factors Associated With the Progression of Myopic Traction Maculopathy in Mexican Patients

Background In this study, the characteristics and prognostic factors associated with the progression of myopic traction maculopathy (MTM) were evaluated in a Mexican population. Methods This is a retrospective observational study that analyzed patients with MTM who underwent optical coherence tomography (OCT). Clinical-ocular information, the MTM classification, and initial and final visual acuity (VA) were recorded. Results In total, 101 eyes of 84 patients (mean age 63.5 ± 10.7 years) were included (88.1% female and 11.9% male). The mean spherical equivalent was -16.8 ± 6.4 D, axial length was 29.6 ± 2.1 mm, and mean initial VA was 0.8 ± 0.5 logMAR. The mean follow-up time was 25.7 ± 27.6 months. The change in final VA from diagnosis to the last follow-up was +0.1 (0.2) (p = 0.001). Overall, 24.8% of patients progressed, 72.3% did not progress, and 3% showed regression. The patient-year progression rate was 0.20 ± 0.44. Factors associated with progression were initial logMAR VA (p= 0.012) and staphyloma (p= 0.001). Conclusions One in four patients with MTM progressed, and the patient-year progression rate was 0.5. The factors associated with disease progression were initial VA and the presence of staphyloma. The characteristics of Mexican patients with MTM are similar to those described in other populations.

Effect of intraocular pressure reduction on progressive high myopia (PHM study): study protocol of a randomised controlled trial

BACKGROUND

In adult patients with high myopia (HM), progressive axial elongation poses a significant risk for the development of subsequent ocular complications that may lead to visual impairment. Effective strategies to reduce or prevent further axial elongation in highly myopic adult patients have not been available so far. Recent studies suggested that medically lowering intraocular pressure (IOP) may reduce axial elongation.

OBJECTIVE

This clinical randomised controlled trial (RCT) aims to evaluate the efficacy of medical IOP reduction in adult patients with progressive HM (PHM).

TRIAL DESIGN

Single-centre, open-label, prospective RCT.

METHODS

This RCT will recruit 152 participants with PHM at the Zhongshan Ophthalmic Center (ZOC). Randomised in a ratio of 1:1, participants will receive IOP-lowering eyedrops (intervention group) or will be followed without treatment (control group) for 12 months. Follow-up visits will be conducted at 1, 6 and 12 months after baseline. Only one eye per eligible participant will be included for analysis. The primary outcome is the change in axial length (AL) within the study period of 12 months. Secondary outcomes include the incidence and progression of visual field (VF) defects, changes in optic disc morphology and incidence and progression of myopic maculopathy. Difference in AL changes between the two groups will be analysed using linear regression analysis. For the secondary outcomes, a multifactor Poisson regression within a generalised linear model will be used to estimate the relative risk of progression in VF defects and myopic maculopathy, and the rate of thinning in retinal nerve fibre layer and ganglion cell-inner plexiform will be assessed through Kaplan-Meier curves and log-rank tests.

ETHICS AND DISSEMINATION

Full ethics approval for this trial has been obtained from the Ethics Committee of ZOC, Sun Yat-sen University, China (ID: 2023KYPJ110). Results of this trial will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05850936.

Risk factors and patterns for progression of fellow-eye myopic traction maculopathy: a 3-year retrospective cohort study

AIMS

To investigate the effect of preretinal tractional structures (PTS) and posterior scleral structures (PSS) on myopic traction maculopathy (MTM) progression.

METHODS

This retrospective cohort study included 185 fellow highly myopic eyes of 185 participants who underwent surgery for MTM. PTS included epiretinal membrane, incomplete posterior vitreous detachment and their combination. PSS included posterior staphyloma and dome-shaped macula (DSM). The MTM stage was graded according to the Myopic Traction Maculopathy Staging System. Optical coherence tomography was used to identify MTM progression, defined as an upgrade of MTM. The Kaplan-Meier method with log-rank test was used to assess MTM progression over the 3-year follow-up period. Risk factors for progression were identified using Cox regression analysis.

RESULTS

MTM progression was observed in 48 (25.9%) eyes. Three-year progression-free survival (PFS) rates for eyes with PTS, staphyloma and DSM were 53.7%, 58.2% and 90.7%, respectively. Eyes with PTS and staphyloma exhibited lower 3-year PFS rates than those without PTS or staphyloma (P log-rank test =0.002 and <0.001), while eyes with DSM had a higher 3-year PFS rate than eyes without DSM (P log-rank test=0.01). Multivariate Cox regression analysis showed that PTS (HR, 3.23; p<0.001) and staphyloma (HR, 7.91; p<0.001) were associated with MTM progression, whereas DSM (HR, 0.23; p=0.046) was a protective factor.

CONCLUSION

Both PTS and PSS play a critical role in the progression of MTM. Addressing these factors can aid in the management of MTM.

Three cases of macular retinal detachment exacerbated during follow-up with myopic foveoschisis around myopic choroidal neovascularization

Purpose

Myopic choroidal neovascularization (CNV) and myopic traction maculopathy are major complications of pathologic myopia, and myopic foveoschisis (MF) is one of several symptoms that can be included under the general term "myopic traction maculopathy"; however, only a few cases will have MF around the myopic CNV. We report three cases with MF around myopic CNV that followed different clinical courses observed using swept-source optical coherence tomography.

Observations

Case 1 was a 69-year-old woman with an axial length of 29.71 mm, myopic CNV, and MF in the left eye. One month after intravitreal injection of ranibizumab (IVR), a macular retinal detachment (RD) expanded. Vitrectomy and gas tamponade were performed during month 2; the macular RD and MF resolved gradually thereafter. Case 2 was a 54-year-old man with an axial length of 30.59 mm, myopic CNV, and MF in the right eye; after IVR, a macular RD developed and gradually expanded until month 4; the RD and MF resolved spontaneously and resolved during month 8. Case 3 was a 66-year-old woman with an axial length of 28.63 mm, myopic CNV, and MF in the left eye. A macular RD expanded 1 month after a previous vitrectomy for MF; after intravitreal injection of aflibercept, the macular RD and MF resolved gradually in month 12. In all cases, the CNV was accompanied by subretinal fluid, and two of the three cases had outer lamellar holes.

Conclusion and Importance

The MF around the myopic CNV may lead to exacerbated MF and RD during follow-up, and the subretinal fluid caused by the CNV might facilitate MF progression. Since this condition is rare, further investigation of this entity is needed to determine appropriate management.

Impact of macular buckle removal on the functional and anatomical outcomes of myopic macular hole associated retinal detachment

A man in his 70s presented with a 1-month history of vision loss in the right eye. His best-corrected visual acuity (BCVA) in the affected eye was limited to counting fingers at close range. The examination revealed a macular hole with associated retinal detachment in the right eye and features of pathological myopia in both eyes. A macular buckling surgery was performed and resulted in a successful anatomical and functional outcome. Postoperatively, at week 10, the patient developed diplopia and buckle exposure. Therefore, the buckle was removed. However, the patient maintained a BCVA of 20/250 with an attached retina and closed macular hole after 6 months of follow-up.

Characteristics and outcomes of full-thickness macular holes created during vitrectomy for proliferative diabetic retinopathy

PURPOSE

To investigate the clinical features, management, and prognosis of full-thickness macular holes (FTMHs) inadvertently created during vitrectomy for eyes with proliferative diabetic retinopathy (PDR) and fibrovascular proliferation (FVP).

METHODS

Eyes with PDR and FVP that had intraoperatively created FTMHs were retrospectively collected as the study group, and age- and sex-matched subjects with PDR and FVP who did not have intraoperative FTMHs were selected as the control group. Fundus abnormalities, optical coherence tomography (OCT) features, and anatomical and functional outcomes were compared between the two groups.

RESULTS

Eleven eyes of 11 patients (5 male and 6 female) were identified as the study group. Follow-up duration was 36.8 ± 47.2 months. FTMHs were managed by ILM peeling or the inverted ILM flap technique. Anatomical success and MH closure were achieved in 100% of eyes in the study group. In comparison to the control group, the study group had a higher proportion of condensed prefoveal tissue (63.6% vs. 22.7%, p = 0.028), and a higher ratio of silicone oil tamponade (63.6% vs. 18.2%, p = 0.014), whereas there were no differences in preoperative and final BCVA, and the severity, activity, and locations of FVP between the two groups.

CONCLUSION

Condensed prefoveal tissue was a risk factor of FTMHs created during operation for eyes with PDR and FVP. The ILM peeling or the inverted ILM flap technique may be beneficial for the treatment with favorable anatomical and functional outcomes.

Optic Nerve Head Abnormalities in Nonpathologic High Myopia and the Relationship With Visual Field

PURPOSE

To describe the optic nerve head (ONH) abnormalities in nonpathologic highly myopic eyes based on swept-source optical coherence tomography (OCT) and the relationship with visual field (VF).

DESIGN

Secondary analysis from a longitudinal cohort study.

METHODS

Highly myopic patients without myopic maculopathy of category 2 or higher were enrolled. All participants underwent a swept-source OCT examination focused on ONH. We differentiated between 3 major types (optic disc morphologic abnormality, papillary/peripapillary tissue defect, and papillary/peripapillary schisis) and 12 subtypes of ONH abnormalities. The prevalence and characteristics of ONH abnormalities and the relationship with VF were analyzed.

RESULTS

A total of 857 participants (1389 eyes) were included. Among the 1389 eyes, 91.86%, 68.61%, and 34.92% of them had at least 1, 2, or 3 ONH abnormalities, respectively, which corresponded to 29.55%, 31.79%, and 35.67% of VF defects, respectively. Among the 12 subtypes of the 3 major types, peripapillary hyperreflective ovoid mass-like structure, visible retrobulbar subarachnoid space, and prelaminar schisis were the most common, respectively. Perimetric defects corresponding to OCT abnormalities were more commonly found in eyes with peripapillary retinal detachment, peripapillary retinoschisis, and peripapillary hyperreflective ovoid mass-like structure. Glaucoma-like VF defects were more common in eyes with deep optic cups (28.17%) and with optic disc pit/pit-like change (18.92%).

CONCLUSIONS

We observed and clarified the ONH structural abnormalities in eyes with nonpathologic high myopia. These descriptions may be helpful to differentiate changes in pathologic high myopia or glaucoma.

Lesion detection with fine-grained image categorization for myopic traction maculopathy (MTM) using optical coherence tomography

BACKGROUND

Myopic traction maculopathy (MTM) are retinal disorder caused by traction force on the macula, which can lead to varying degrees of vision loss in eyes with high myopia. Optical coherence tomography (OCT) is an effective imaging technique for diagnosing, detecting and classifying retinopathy. MTM has been classified into different patterns by OCT, corresponding to different clinical strategies.

PURPOSE

We aimed to engineer a deep learning model that can automatically identify MTM in highly myopic (HM) eyes using OCT images.

METHODS

A five-class classification model was developed using 2837 OCT images from 958 HM patients. We adopted a ResNet-34 architecture to train the model to identify MTM: no MTM (class 0), extra-foveal maculoschisis (class 1), inner lamellar macular hole (class 2), outer foveoschisis (class 3), and discontinuity or detachment of foveal outer hyperreflective layers (class 4). An independent test set of 604 images from 173 HM patients was used to evaluate the model's performance. Classification performance was assessed according to the area under the curve (AUC), accuracy, sensitivity, specificity.

RESULTS

Our model exhibited a high training performance for classification (F1-score of 0.953; AUCs of 0.961 to 0.998). In test set, it achieved sensitivities (91.67%-97.78 %) and specificities (98.33%-99.17%) as good as, or better than, those of experienced clinicians. Heatmaps were generated to provide visual explanations.

CONCLUSIONS

We established a deep learning model for MTM classification using OCT images. This model performed equally well or better than retinal specialists and is suitable for large-scale screening and identifying MTM in HM eyes.

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.

LONG-TERM PROGRESSION PATTERN OF MYOPIC TRACTIONAL MACULOPATHY: Outcomes and Risk Factors

PURPOSE

To evaluate the long-term progression pattern of myopic tractional maculopathy and the risk factors.

METHODS

The prevalence and grade of myopic tractional maculopathy were assessed with optical coherence tomography at enrollment and at the 2-year follow-up. The severity of posterior staphyloma and the presence of dome-shaped macula were also evaluated.

RESULTS

In total, 610 highly myopic eyes of 610 patients were analyzed. The prevalence of epiretinal membrane, myopic retinoschisis, and macular hole increased from 26.7%, 12.1%, and 4.4% at enrollment to 41.1%, 18.2%, and 9.5% at the 2-year follow-up, respectively. Epiretinal membrane progressed in 21.8% of eyes, but visual acuity did not decline significantly in these eyes. Myopic retinoschisis progressed in 6.8% of eyes, and macular hole progressed in 14.8% of eyes. Significantly greater best-corrected visual acuity reduction was detected in the eyes with myopic retinoschisis or macular hole progression than the rest ( P < 0.05). Multivariate analysis showed that longer axial length, more-severe posterior staphyloma, and absence of dome-shaped macula were associated with myopic tractional maculopathy progression.

CONCLUSION

In highly myopic eyes, long-term visual acuity was relatively stable in those with epiretinal membrane, but was significantly affected by myopic retinoschisis or macular hole progression. Longer axial length, more-severe posterior staphyloma, and absence of dome-shaped macula were risk factors for myopic tractional maculopathy progression.

Surgical Outcomes of Myopic Foveoschisis According to the ATN Classification System

INTRODUCTION

This study compared the surgical outcomes in eyes with myopic foveoschisis (MF) according to the recently developed ATN classification system.

METHODS

This was an observational case series of 64 consecutive eyes that underwent vitrectomy for MF. Eyes were classified into severe myopic maculopathy (MM) (n = 43) and non-severe MM (n = 21) groups according to the ATN classification system. The primary outcome measures constituted best-corrected visual acuity (BCVA) and anatomical changes.

RESULTS

In total, BCVA improved from 0.97 to 0.53 (P < 0.001) after surgery. The ATN score was significantly lower in the eyes with vision improvement than those without vision improvement (P < 0.001). In the subgroup, BCVA improved from 0.79 to 0.28 in the non-severe MM group (P < 0.001), and improved from 1.05 to 0.65 in the severe MM group (P = 0.001) after surgery. The non-severe MM group achieved better postoperative BCVA (P = 0.001) and were more likely to gain vision improvement (P < 0.001) after surgery compared with the severe MM group. Anatomical success was achieved in 62 of the 64 eyes (96.88%). Two eyes with anatomical failure developed full-thickness macular holes postoperatively; both were in the severe MM group.

CONCLUSIONS

For patients with MF, different severity of MM based on ATN classification could lead to a significantly different prognosis after surgery. For patients with high ATN scores, the operative decision should be made cautiously for the worse anatomical and visual prognosis. ATN system is instructive in making operative proposals for MF.

Myopic macular diseases: A review

Recent evidence has demonstrated that the global public health burden of myopia is rising rapidly. Highly myopic eyes are associated with increased frequency of eye disorders that can lead to irreversible visual impairment. With recent technological advancement in ophthalmic imaging modalities, various macular complications associated with pathologic myopia are being elucidated. The development and progression of myopic chorioretinal atrophy, myopic macular neovascularization, myopic traction maculopathy and dome-shaped macula are vision-threatening myopic macular diseases. In order to overcome the challenges in managing patients with pathologic myopia, it is important to have a complete understanding in the natural course of these myopic macular diseases. Standardising the classification criteria of pathologic myopia is essential for enhancing clinical surveillance. Personalised pharmaceutical therapy and surgical interventions will help to optimise the treatment outcomes in patients suffering from these myopic macular diseases.

Posterior scleral reinforcement for the treatment of myopic traction maculopathy

Background

This study aimed to investigate the clinical effectiveness of posterior scleral reinforcement(PSR) for the treatment of myopic traction maculopathy (MTM).

Methods

This was a prospective study of 32 eyes from 20 patients with MTM treated with PSR using genipin-cross-linked donor sclera. The length of the scleral strip used for the surgery was designed to be 1.5-times the axial length of the eye, whereas its width was 0.4-times the axial length of the eye. The optical coherence tomography images, spherical equivalent of refractive error, axial length, best corrected visual acuity, electroretinogram findings, and intraocular pressure of the patients were assessed postoperatively.

Results

The mean duration of follow-up was 17.80 ± 8.74 months. The differences between the spherical equivalent of refractive error, best corrected visual acuity, axial length, and electroretinogram findings recorded preoperatively and those measured postoperatively were statistically significant (p < 0.05). The final reduction in axial length was 1.64 ± 0.85 mm. At the end of the follow-up, optical coherence tomography showed essential foveal reattachment in 30 eyes (93.75%), partial reattachment in two eyes (6.25%), and closure of macular holes in seven eyes (77.78%). No retinal detachment, vitreous haemorrhage, or other serious complications occurred following the surgery.

Conclusions

Posterior scleral reinforcement with genipin-cross-linked sclera showed safe and effective outcomes for the treatment of MTM during a follow-up period of at least one year.

Trial registration

11\12\2018, ChiCTR1800020012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02497-6.

Advances in OCT Imaging in Myopia and Pathologic Myopia

Advances in imaging with optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) technology, including the development of swept source OCT/OCTA, widefield or ultra-widefield systems, have greatly improved the understanding, diagnosis, and treatment of myopia and myopia-related complications. Anterior segment OCT is useful for imaging the anterior segment of myopes, providing the basis for implantable collamer lens optimization, or detecting intraocular lens decentration in high myopic patients. OCT has enhanced imaging of vitreous properties, and measurement of choroidal thickness in myopic eyes. Widefield OCT systems have greatly improved the visualization of peripheral retinal lesions and have enabled the evaluation of wide staphyloma and ocular curvature. Based on OCT imaging, a new classification system and guidelines for the management of myopic traction maculopathy have been proposed; different dome-shaped macula morphologies have been described; and myopia-related abnormalities in the optic nerve and peripapillary region have been demonstrated. OCTA can quantitatively evaluate the retinal microvasculature and choriocapillaris, which is useful for the early detection of myopic choroidal neovascularization and the evaluation of anti-vascular endothelial growth factor therapy in these patients. In addition, the application of artificial intelligence in OCT/OCTA imaging in myopia has achieved promising results.

Pathologic myopia: advances in imaging and the potential role of artificial intelligence

Pathologic myopia is a severe form of myopia that can lead to permanent visual impairment. The recent global increase in the prevalence of myopia has been projected to lead to a higher incidence of pathologic myopia in the future. Thus, imaging myopic eyes to detect early pathological changes, or predict myopia progression to allow for early intervention, has become a key priority. Recent advances in optical coherence tomography (OCT) have contributed to the new grading system for myopic maculopathy and myopic traction maculopathy, which may improve phenotyping and thus, clinical management. Widefield fundus and OCT imaging has improved the detection of posterior staphyloma. Non-invasive OCT angiography has enabled depth-resolved imaging for myopic choroidal neovascularisation. Artificial intelligence (AI) has shown great performance in detecting pathologic myopia and the identification of myopia-associated complications. These advances in imaging with adjunctive AI analysis may lead to improvements in monitoring disease progression or guiding treatments. In this review, we provide an update on the classification of pathologic myopia, how imaging has improved clinical evaluation and management of myopia-associated complications, and the recent development of AI algorithms to aid the detection and classification of pathologic myopia.

Intra- and interobserver concordance of a new classification system for myopic maculopathy

BACKGROUND

Myopic maculopathy (MM) is one of the major causes of visual impairment and irreversible blindness in eyes with pathologic myopia (PM). However, the classification of each type of lesion associated with MM has not been determined. Recently, a new MM classification system, known as the ATN grading and classification system, was proposed; it is based on the fundus photographs and optical coherence tomography (OCT) images and includes three variable components: atrophy (A), traction (T), and neovascularization (N). This study aimed to perform an independent evaluation of interobserver and intraobserver agreement for the recently developed ATN grading system for MM.

METHODS

This was a retrospective study. Fundus photographs and OCT images of 125 patients (226 eyes) with various MMs were evaluated and classified using the ATN grading of the new MM classification system by four blinded and independent evaluators (2 attending ophthalmologists and 2 ophthalmic residents). All cases were randomly re-evaluated by the same observers after an interval of 6 weeks. The kappa coefficient (κ) and 95% confidence interval (CI) were used to determine the interobserver and intraobserver agreement.

RESULTS

The interobserver agreement was substantial when considering the maculopathy type (A, T, and N). The weighted Fleiss κ values for each MM type (A, T, and N) were 0.651 (95% CI: 0.602-0.700), 0.734 (95% CI: 0.689-0.779), and 0.702 (95% CI: 0.649-0.755), respectively. The interobserver agreement when considering the subtypes was good or excellent, except for stages A1, A2, and N1, in which the weighted κ value was less than 0.6, with moderate agreement. The intraobserver agreement of types and subtypes was excellent, with κ > 0.8. No significant differences were observed between the attending ophthalmologists and residents for interobserver reliability or intraobserver reproducibility.

CONCLUSIONS

The ATN classification allows an adequate agreement among ophthalmologists with different qualifications and by the same observer on separate occasions. Future prospective studies should further evaluate whether this classification can be better implemented in clinical decision-making and disease progression assessments.