Progressive change in peripapillary atrophy in myopic glaucomatous eyes

Clinical Characteristics and Associated Factors to the Development of Glaucoma in Eyes With Myopic Optic Neuropathy

PURPOSE

To observe the development of glaucoma in myopic eyes with and without myopic optic neuropathy (MON) and analyze associated factors to the development of typical glaucomatous damage.

DESIGN

A prospective, observational, cohort study.

METHODS

A total of 233 myopic eyes with no definite evidence of glaucomatous damage were included. Myopic patients without any retinal nerve fiber layer (RNFL) or visual field (VF) abnormalities were classified as myopic eyes without MON. Myopic patients with decreased RNFL at the superonasal (SN) or nasal area, and with corresponding VF defects either in the temporal or inferotemporal (IT) region were classified as myopic eyes with MON. Myopic eyes that developed glaucoma were defined by the presence of glaucomatous VF in the SN region including defects in Bjerrum area, or a new localized RNFL defect in the IT region. Disc morphological features and optic nerve head (ONH) parameters of two groups were compared.

RESULTS

Myopic eyes with MON had a thinner average peripapillary RNFL thickness (P < 0.001), worse MD of the VF (P = 0.031), a higher percentage of IT VF defects (P < 0.001), smaller torsion degree (P = 0.047), and greater LCD (P = 0.022). Myopic eyes with MON who developed glaucoma had a thinner average peripapillary RNFL thickness (P = 0.009), greater PPA area (P = 0.049), greater LCD (P < 0.001), and thinner LCT (P < 0.001). Thinner baseline temporal RNFL thickness (HR, 0.956; 95% CI, 0.928-0.986; P = 0.004), greater baseline LCD (HR, 1.003; 95% CI, 1.000-1.005; P = 0.022), and greater PPA area (HR, 1.000; 95% CI, 1.000-1.003; P = 0.050) were significantly associated factors with glaucoma development.

CONCLUSIONS

Myopic eyes with MON have a greater risk to develop glaucoma compared to myopic eyes without MON. Structural weakness due to myopia, especially at the temporal side of the ONH and the peripapillary sclera, increases the risk of glaucoma in myopic eyes with MON.

Quantization of Optic Disc Characteristics in Young Adults Based on Artificial Intelligence

PURPOSE

This study aimed to automatically and quantitatively analyse the characteristics of the optic disc by applying artificial intelligence (AI) to fundus images.

METHODS

A total of 1084 undergraduates were recruited in this cross-sectional study. The optic disc area, cup-to-disc ratio (C/D), optic disc tilt, and the area, width, and height of peripapillary atrophy (PPA) were automatically and quantitatively detected using AI. Based on axial length (AL), participants were divided into five groups: Group 1 (AL ≤ 23 mm); Group 2 (23 mm < AL≤ 24 mm); Group 3 (24 mm < AL≤ 25 mm); Group 4 (25 mm < AL< 26 mm) and Group 5 (AL ≥ 26 mm). Relationships between ocular parameters and optic disc characteristics were analysed.

RESULT

A total of 999 undergraduates were included in the analysis. The prevalence of optic disc tilting and PPA were 47.1% and 92.5%, respectively, and increased with the severity of myopia. The mean optic disc area, PPA area, C/D, and optic disc tilt ratio were 1.97 ± 0.46 mm2, 0.84 ± 0.59 mm2, 0.18 ± 0.07, and 0.81 ± 0.08, respectively. In Group 5, the average optic disc area (1.84 ± 0.41 mm2) and optic disc tilt ratio (0.79 ± 0.08) were significantly smaller and the PPA area (1.12 ± 0.61 mm2) was significantly larger than those in the other groups. AL was negatively correlated with optic disc area and optic disc tilt ratio (r=-0.271, -0.219; both p < 0.001) and positively correlated with PPA area, width, and height (r = 0.421, 0.426, 0.345; all p < 0.01). A greater AL (β = 0.284, p < 0.01) and a smaller optic disc tilt ratio (β=-0.516, p < 0.01) were related to a larger PPA area.

CONCLUSION

The characteristics of the optic disc can be feasibly and efficiently extracted using AI. The quantization of the optic disc might provide new indicators for clinicians to evaluate the degree of myopia.

Comparative analysis of OCT-defined parapapillary beta and gamma zones between primary open angle glaucoma and primary angle closure glaucoma

The ophthalmoscopic beta zone of parapapillary atrophy has recently been proposed to divide into a gamma zone and a (new) beta zone based on OCT imaging. The present study was undertaken to compare the microstructural characteristics of parapapillary gamma and beta zones and their influencing factors between primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG). Seventy-three PACG patients that had no evidence of an acute attack and 78 POAG patients were enrolled. Patients were matched by propensity scores for age and visual field mean defect (MD) value. The area and angular extent of both zones were measured. In multivariate analysis, a larger beta zone was correlated with older age, severe MD value and longer axial length. A larger gamma zone was correlated with longer axial length. Older age and severe MD value were correlated with the concentric shape of beta zone. Comparing the PACG and POAG groups that adjusted for age and MD value, gamma zone was larger and more prevalent in the POAG group, while beta zone showed no significant difference. Taken separately, MD value was associated with the area and shape of beta zone in the PACG group. Axial length was associated with the temporal shape of beta zone in the POAG group. These data indicated that OCT-defined parapapillary beta and gamma zones exhibited different characteristics in two types of glaucoma. Clinically, the size of parapapillary beta zone may serve as a better indicator of glaucoma severity in eyes with PACG than that in POAG.

Longitudinal changes of circumpapillary retinal nerve fiber layer thickness profile during childhood myopia progression

The purpose of this study was to evaluate longitudinal changes of circumpapillary retinal nerve fiber layer thickness (cpRNFLT) profile arising in the course of childhood myopia progression. Thirty-six eyes of 36 healthy children who showed myopia progression (spherical equivalent [SE] decrease of ≥ 2.0 diopters [D]) were included. To account for the axial-elongation-induced magnification effect on spectral-domain optical coherence tomography (SD-OCT) measurements, we calculated the proportion of quadrant-cpRNFLT distribution (i.e., the percentage of cpRNFLT within a single quadrant of total cpRNFLT). During 4.1 ± 1.1 years, the mean SE changed from -1.3 ± 0.9 to -4.3 ± 0.8D, and both the optic disc tilt ratio and the torsional angle increased (both P < 0.001). In the temporal quadrant, the cpRNFLT proportion was increased from 19.2 ± 1.86 to 24.4 ± 2.30% (P < 0.001). The cpRNFLT proportion in 3 quadrants (i.e., superior, inferior, nasal) showed decreases (all P < 0.001). Between baseline and follow up, the scan-circle location as determined by OCT was shifted mostly (94%; 34 of 36 eyes) toward the nasal side of the optic disc. With scan-circle repositioning to match the baseline, cpRNFLT distribution proportions did not show any significant difference between the baseline and follow up (all P > 0.05). For longitudinal evaluations of patients with myopia progression, scan-circle alteration should be given due consideration.

Pathological myopia classification with simultaneous lesion segmentation using deep learning

BACKGROUND AND OBJECTIVES

Pathological myopia (PM) is the seventh leading cause of blindness, with a reported global prevalence up to 3%. Early and automated PM detection from fundus images could aid to prevent blindness in a world population that is characterized by a rising myopia prevalence. We aim to assess the use of convolutional neural networks (CNNs) for the detection of PM and semantic segmentation of myopia-induced lesions from fundus images on a recently introduced reference data set.

METHODS

This investigation reports on the results of CNNs developed for the recently introduced Pathological Myopia (PALM) dataset, which consists of 1200 images. Our CNN bundles lesion segmentation and PM classification, as the two tasks are heavily intertwined. Domain knowledge is also inserted through the introduction of a new Optic Nerve Head (ONH)-based prediction enhancement for the segmentation of atrophy and fovea localization. Finally, we are the first to approach fovea localization using segmentation instead of detection or regression models. Evaluation metrics include area under the receiver operating characteristic curve (AUC) for PM detection, Euclidean distance for fovea localization, and Dice and F1 metrics for the semantic segmentation tasks (optic disc, retinal atrophy and retinal detachment).

RESULTS

Models trained with 400 available training images achieved an AUC of 0.9867 for PM detection, and a Euclidean distance of 58.27 pixels on the fovea localization task, evaluated on a test set of 400 images. Dice and F1 metrics for semantic segmentation of lesions scored 0.9303 and 0.9869 on optic disc, 0.8001 and 0.9135 on retinal atrophy, and 0.8073 and 0.7059 on retinal detachment, respectively.

CONCLUSIONS

We report a successful approach for a simultaneous classification of pathological myopia and segmentation of associated lesions. Our work was acknowledged with an award in the context of the "Pathological Myopia detection from retinal images" challenge held during the IEEE International Symposium on Biomedical Imaging (April 2019). Considering that (pathological) myopia cases are often identified as false positives and negatives in glaucoma deep learning models, we envisage that the current work could aid in future research to discriminate between glaucomatous and highly-myopic eyes, complemented by the localization and segmentation of landmarks such as fovea, optic disc and atrophy.

BETA-PERIPAPILLARY ATROPHY AND GEOGRAPHIC ATROPHY IN THE COMPARISON OF AGE-RELATED MACULAR DEGENERATION TREATMENTS TRIALS

PURPOSE

To determine associations between beta-peripapillary atrophy (B-PPA) and incidence and growth of geographic atrophy (GA) in eyes treated with anti-vascular endothelial growth factor agents in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

METHODS

We included 245 cases with incident GA and 245 controls matched by baseline demographics and characteristics associated with development of GA in the CATT. Baseline color images were graded for the type of B-PPA, defined as presence of hypopigmentation with visible choroidal vessels and sclera that is adjacent to the optic disk. Beta-peripapillary atrophy was further classified as scleral ring, sclera, sclera/choroidal blood vessels, or combination. Areas of each type of B-PPA and the circumferential extent of B-PPA were measured.

RESULTS

Beta-peripapillary atrophy was present in 58% of eyes developing GA and in 52% without GA (P = 0.17). The greater circumferential extent of sclera/choroidal blood vessels B-PPA in relation to the optic disk was associated with incident GA (P = 0.02) and the GA size at first observation (P = 0.047). Beta-peripapillary atrophy was not associated with GA growth rates (P>0.05). Patients without B-PPA had a higher number of GA-associated risk alleles of ARMS2 (P = 0.0003) and HTRA1 (P = 0.001).

CONCLUSION

The extent of sclera/choroidal blood vessel B-PPA was associated with the GA incidence and size but not with the growth rate in eyes treated for neovascular age-related macular degeneration. Beta-peripapillary atrophy and GA may share some common pathophysiologic pathways unrelated to the GA-associated risk alleles evaluated.

Optic nerve head anatomy in myopia and glaucoma, including parapapillary zones alpha, beta, gamma and delta: Histology and clinical features

The optic nerve head can morphologically be differentiated into the optic disc with the lamina cribrosa as its basis, and the parapapillary region with zones alpha (irregular pigmentation due to irregularities of the retinal pigment epithelium (RPE) and peripheral location), beta zone (complete RPE loss while Bruch's membrane (BM) is present), gamma zone (absence of BM), and delta zone (elongated and thinned peripapillary scleral flange) within gamma zone and located at the peripapillary ring. Alpha zone is present in almost all eyes. Beta zone is associated with glaucoma and may develop due to a IOP rise-dependent parapapillary up-piling of RPE. Gamma zone may develop due to a shift of the non-enlarged BM opening (BMO) in moderate myopia, while in highly myopic eyes, the BMO enlarges and a circular gamma zone and delta zone develop. The ophthalmoscopic shape and size of the optic disc is markedly influenced by a myopic shift of BMO, usually into the temporal direction, leading to a BM overhanging into the intrapapillary compartment at the nasal disc border, a secondary lack of BM in the temporal parapapillary region (leading to gamma zone in non-highly myopic eyes), and an ocular optic nerve canal running obliquely from centrally posteriorly to nasally anteriorly. In highly myopic eyes (cut-off for high myopia at approximately -8 diopters or an axial length of 26.5 mm), the optic disc area enlarges, the lamina cribrosa thus enlarges in area and decreases in thickness, and the BMO increases, leading to a circular gamma zone and delta zone in highly myopic eyes.

Progressive Optic Disc Tilt in Young Myopic Glaucomatous Eyes

Purpose

To explore the progressive change and associated factors of optic disc tilt in young myopic glaucomatous eyes by analyzing long-term follow-up data.

Methods

Optic disc images were obtained from spectral-domain optical coherence tomography enhanced depth imaging from at least five different visits. At each visit, the disc tilt angle (DTA), defined as the angle between the Bruch's membrane opening plane and the optic canal plane, was estimated at the central frame that passes through the optic disc. Glaucoma progression was assessed on the basis of changes noted on serial optic disc and retinal nerve fiber layer photographs or changes in the visual field (VF). A linear mixed effect model was used to assess the influence of parameters (age, sex, baseline and follow-up intraocular pressure, retinal nerve fiber layer thickness, VF mean deviation, axial length, central corneal thickness), and presence of glaucomatous progression upon DTA change.

Results

A total of 26 eyes of 26 young myopic primary open-angle glaucoma patients (axial length >24.0 mm; mean age, 25.1 ± 4.0 years; mean follow-up, 3.3 ± 0.9 years) were included. DTA was 7.0 ± 3.4 degrees at baseline and 8.3 ± 3.8 degrees at last visit, which represents a significant difference (p < 0.001). Worse VF mean deviation (p < 0.001) and longer axial length (p = 0.006) were significantly associated with DTA increase.

Conclusions

Young myopic glaucomatous eyes showed progressive optic disc tilting. Progressive optic disc tilting in young myopic glaucomatous eyes may be related to either continuous axial myopic shift or glaucomatous structural change.

Morphological characteristics of parapapillary atrophy and subsequent visual field progression in primary open-angle glaucoma

BACKGROUND/AIMS

To investigate the associations between the morphological characteristics of beta-zone parapapillary atrophy (β-zone PPA) and subsequent visual field (VF) progression in eyes with primary open-angle glaucoma (POAG).

METHODS

One hundred and twenty-one POAG eyes with β-zone PPA along with 48 normal eyes with β-zone PPA were included. β-zone PPA area was calculated based on the PPA pixel area/optic-disc pixel area ratio and the optical coherence tomography (OCT)-measured disc area. β-zone PPA margin irregularity was quantified as a function of both area (A) and perimeter (P, calculated as 1/(4πA/P²)). VF progression was defined using standard automated perimetry's guided progression analysis software.

RESULTS

Of the 121 POAG eyes, 49 (40.5%) showed VF progression during the 10.1±1.9 years of follow-up. The baseline β-zone PPA area was similar among the three groups (Progressors, Non-progressors and Controls, p=0.995). However, the β-zone PPA irregularity index was significantly higher in the Progressors (p<0.001). The cumulative probability of VF progression was greater in the higher PPA irregularity index group (p<0.001, log-rank test). A Cox proportional hazards model showed the significant influences of optic disc haemorrhage (HR: 2.661, p=0.034) and higher baseline PPA irregularity index (HR: 1.455, p=0.007) on subsequent progression.

CONCLUSIONS

In POAG eyes, baseline β-zone PPA margin regularity was significantly associated with subsequent VF progression. Irregular margin of β-zone PPA might be the mark of vulnerability in the parapapillary area to further glaucomatous damage.

Ten Years and Beyond Longitudinal Change of ß-Zone Parapapillary Atrophy: Comparison of Primary Open-Angle Glaucoma with Normal Eyes

PURPOSE

To investigate the difference in longitudinal change of ß-zone parapapillary atrophy (PPA) between eyes with primary open-angle glaucoma (POAG) and normal eyes.

DESIGN

Longitudinal, observation study.

PARTICIPANTS

A total of 153 eyes with POAG and 105 normal eyes.

METHODS

Participants were followed for 10 years or more, with disc photography performed every year. The topographic parameters of ß-zone PPA (area, maximal radial extent, angular extent around disc) were measured. The factors associated with the enlargement of ß-zone PPA parameters were assessed by odds ratio (OR) using multivariable logistic regression.

MAIN OUTCOME MEASURES

Enlargement of ß-zone PPA parameters and associated factors.

RESULTS

Over the course of the average 11.6±1.3-year follow-up period, enlargement of β-zone PPA was detected in 66.7% of POAG eyes and in 26.7% of normal eyes. Increment of all PPA parameters was significantly more common in cases of POAG than in normal eyes (all P < 0.001). The spatial distribution of maximal radial extent at baseline and final examination was significantly different between the 2 groups: POAG eyes; inferotemporal versus normal eyes; temporal (chi-square = 26.549, P < 0.001, chi-square = 19.320, P = 0.004, respectively). The widening of radial extent was significantly associated with older age (OR, 1.036; P = 0.010) and the presence of glaucoma (OR, 2.599; P = 0.002). The increment of angular extent was associated with the presence of glaucoma (OR, 12.167; P = 0.017) and optic disc hemorrhage (OR, 3.266; P = 0.019).

CONCLUSIONS

The pattern of ß-zone PPA change differed between POAG and normal eyes during a follow-up of 10 years or more. The enlargement of PPA occurred more frequently in POAG than in normal eyes. The widening of radial extent was associated with older age and glaucoma, whereas the increment of angular extent was associated with glaucomatous damage.