Progression of Myopic Maculopathy in Highly Myopic Chinese Eyes

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.

Forecasting Myopic Maculopathy Risk Over a Decade: Development and Validation of an Interpretable Machine Learning Algorithm

Purpose

The purpose of this study was to develop and validate prediction model for myopic macular degeneration (MMD) progression in patients with high myopia.

Methods

The Zhongshan High Myopia Cohort for model development included 660 patients aged 7 to 70 years with a bilateral sphere of ≤-6.00 diopters (D). Two hundred twelve participants with an axial length (AL) ≥25.5 mm from the Chinese Ocular Imaging Project were used for external validation. Thirty-four clinical variables, including demographics, lifestyle, myopia history, and swept source optical coherence tomography data, were analyzed. Sequential forward selection was used for predictor selection, and binary classification models were created using five machine learning algorithms to forecast the risk of MMD progression over 10 years.

Results

Over a median follow-up of 10.9 years, 133 patients (20.2%) showed MMD progression in the development cohort. Among them, 69 (51.9%) developed newly-onset MMD, 11 (8.3%) developed patchy atrophy from diffuse atrophy, 54 (40.6%) showed an enlargement of lesions, and 9 (6.8%) developed plus signs. Top six predictors for MMD progression included thinner subfoveal choroidal thickness, longer AL, worse best-corrected visual acuity, older age, female gender, and shallower anterior chamber depth. The eXtreme Gradient Boosting algorithm yielded the best discriminative performance (area under the receiver operating characteristic curve [AUROC] = 0.87 ± 0.02) with good calibration in the training cohort. In a less myopic external validation group (median -5.38 D), 48 patients (22.6%) developed MMD progression over 4 years, with the model's AUROC validated at 0.80 ± 0.008.

Conclusions

Machine learning model effectively predicts MMD progression a decade ahead using clinical and imaging indicators. This tool shows promise for identifying "at-risk" high myopes for timely intervention and vision protection.

Four-Year Progression of Myopic Maculopathy in Children and Adolescents With High Myopia

Importance

Individuals with high myopia younger than 18 years are at relatively high risk of progressively worsening myopic maculopathy. Additional studies are needed to investigate the progression of myopic maculopathy in this age group, as well as the risk factors associated with progression.

Objective

To investigate the 4-year progression of myopic maculopathy in children and adolescents with high myopia, and to explore potential risk factors.

Design, Setting, and Participants

This hospital-based observational study with 4-year follow-up included a total of 548 high myopic eyes (spherical power -6.00 or less diopters) of 274 participants aged 7 to 17 years. Participants underwent comprehensive ophthalmic examination at baseline and 4-year follow-up. Myopic maculopathy was accessed by the International Photographic Classification and Grading System. The data analysis was performed from August 1 to 15, 2023.

Main Outcomes and Measures

The progression of myopic maculopathy progression over 4 years and associated risk factors.

Results

The 4-year progression of myopic maculopathy was found in 67 of 548 eyes (12.2%) of 274 participants (138 girls [50.4%] at baseline and 4-year follow-up) with 88 lesion changes, including new signs of the tessellated fundus in 16 eyes (18.2%), diffuse atrophy in 12 eyes (13.6%), patchy atrophy in 2 eyes (2.3%), lacquer cracks in 9 eyes (10.2%), and enlargement of diffuse atrophy in 49 eyes (55.7%). By multivariable analysis, worse best-corrected visual acuity (odds ratio [OR], 6.68; 95% CI, 1.15-38.99; P = .04), longer axial length (AL) (OR, 1.73; 95% CI, 1.34-2.24; P < .001), faster AL elongation (OR, 302.83; 95% CI, 28.61-3205.64; P < .001), and more severe myopic maculopathy (diffuse atrophy; OR, 4.52; 95% CI, 1.98-10.30; P < .001 and patchy atrophy; OR, 3.82; 95% CI, 1.66-8.80; P = .002) were associated with myopic maculopathy progression.

Conclusions and Relevance

In this observational study, the progression of myopic maculopathy was observed in approximately 12% of pediatric high myopes for 4 years. The major type of progression was the enlargement of diffuse atrophy. Risk factors for myopic maculopathy progression were worse best-corrected visual acuity, longer AL, faster AL elongation, and more severe myopic maculopathy. These findings support consideration of follow-up in these individuals and trying to identify those at higher risk for progression.

Association between Fundus Tessellation and Contrast Sensitivity in Myopic Eyes

PURPOSE

To assess the association of fundus tessellation with contrast sensitivity, Quality of Vision questionnaire, and other factors at five years postcorneal refractive surgery.

METHODS

This is a cross-sectional study. Both eyes of 98 subjects (196 eyes) who received femtosecond laser in situ keratomileusis (FS-LASIK) or small incision lenticular extraction (SMILE) five years prior were enrolled in this study. Fundus tessellation was imaged using wide-angle fundus photographs and graded into four categories with the assistance of the ETDRS grid. Photopic and mesopic contrast sensitivity were measured under the best correction. The Quality of Vision (QoV) questionnaire was used to assess visual symptoms.

RESULTS

Fundus tessellation was classified as follows: 19 eyes were grade 0 (9.7%), 28 eyes were grade 1 (14.3%), 59 eyes were grade 2 (30.1%), and 90 eyes were grade 3 (45.9%). Higher degrees of fundus tessellation were associated with lower photopic contrast sensitivity, a significant difference was observed at spatial frequencies of 6cpd (p = 0.030, grade 1 >grade 3 p = 0.011). Higher degrees of fundus tessellation were also associated with lower mesopic contrast sensitivity, a significant difference was observed at spatial frequencies of 18cpd (p = 0.011, grade 0 >grade 3 p = 0.012). The preoperative degree of myopia was positively associated with fundus tessellation grade (p < 0.001). However, in linear mixed-effect model analysis, no significant influence of parameters (contrast sensitivity, preoperative myopia, and QoV scores) upon different tessellation grades was found (p > 0.05).

CONCLUSIONS

Patients with moderate and high myopia were more likely to have higher grades of fundus tessellation. Higher degree of fundus tessellation associates with lower contrast sensitivity. Patients with moderate and high myopia should be concerned with retinal-choroidal changes. Contrast sensitivity could be a clinical sign for progression of tessellation and used to screen for early retinal-choroidal changes to prevent pathologic myopia.

Clinical Features of Fundus Tessellation and Its Relationship with Myopia: A Systematic Review and Meta-analysis

INTRODUCTION

This study aims to assess the existing literature on fundus tessellation (FT), focusing on its prevalence, associated factors, distribution, and progression.

METHODS

Systemic methods were employed to search and gather published literature on FT from databases such as the National Library of Medicine (PubMed), Web of Science (WOS), and Elsevier on July 1, 2023. The quality of the studies was evaluated using the Newcastle-Ottawa Scale (NOS) and the Healthcare Research and Quality (AHRQ) criteria. A meta-analysis was conducted to compare tessellated and normal fundus with respect to age, gender, axial length, and spherical equivalent.

RESULTS

The systematic review included 23 articles, encompassing a total of 3053 eyes in the meta-analysis. The prevalence of FT varied from 43.00 to 94.35%. The severity of FT was significantly associated with older age, male sex, lower body weight index, longer axial length, larger peripapillary atrophy, thinner choroid, thinner sclera, and larger corneal radius of curvature, suggesting a potential progression pattern. Notably, FT was observed predominantly in the macular and peripapillary regions. The meta-analysis revealed that tessellated fundus tended to be associated with older age (mean difference [MD] 4.76, 95% confidence interval [CI] 1.71-7.80, P < 0.01), longer axial length (MD 0.86, 95% CI 0.70-1.02, P < 0.01), and a lower spherical equivalent (MD - 1.16, 95% CI - 1.68 to 0.65, P < 0.01) compared to normal fundus. However, there was no significant difference in the proportion of males between individuals with tessellated and normal fundus (odds ratio [OR] 1.12, 95% CI 0.89-1.42, P = 0.32).

CONCLUSIONS

Overall, this systematic review and meta-analysis shed light on the prevalence, characteristics, and factors associated with FT, offering valuable insights for clinicians and researchers in the field of ophthalmology.

STUDY REGISTRATION

The study protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023442486).

Spontaneously Myopic Guinea Pig: Model of Early Pathologic Myopia

Purpose

To evaluate whether pigmented guinea pigs with spontaneous myopia present characteristic changes of pathologic myopia.

Methods

The fundus images of guinea pigs (3 weeks old) were graded according to fundus tessellation (FT) degree. Biometric parameters, including refraction, vitreous chamber depth (VCD), and axial length (AL), were measured at ages 21 and 43 days. Some of these animals were divided into three groups: hyperopic without FT (H w/o FT), myopic without FT (M w/o FT), and myopic with FT (M w/ FT). The horizontal and vertical radii of curvature of posterior sclera (RP-H and RP-V, respectively) and the radii of curvature and arc lengths of superior sclera (RS and LS, respectively), inferior sclera (RI and LI, respectively), nasal sclera (RN and LN, respectively), and temporal sclera (RT and LT) were evaluated by Fuji.

Results

The fundi were graded as type A or type B (both without FT), type C (mild FT), or type D (severe FT). The prevalence of FT was correlated with myopic refraction, longer VCD, and longer AL. Eyes of M w/FT animals had shorter RP-H and RP-V, longer RS and RT, and longer LS and LT than eyes of H w/o FT or M w/o FT animals. Refractions shifted toward hyperopia in eyes lacking FT, but not in eyes having FT. The changes in VCD were consistent with the changes in refraction. This relatively myopic shift in refraction and shortening of VCD were found only in myopic eyes with FT, but not in myopic eyes without FT.

Conclusions

Spontaneously myopic guinea pig eyes have a high prevalence of FT. Myopic eyes with FT presented characteristic signs of pathologic myopia.

Correlation of Visual Acuity and Outer Retinal Thickness in Myopic Atrophic Maculopathy: A Retrospective Review

INTRODUCTION

Myopic atrophic maculopathy is prevalent among patients with pathologic myopia and frequently leads to relentless vision loss. Several grading systems were established to facilitate the understanding of myopic atrophic maculopathy. However, the anatomical details in different stages of myopic maculopathy are so far not clearly elucidated. This study aims to investigate the visual acuity and retinal sublayer features in highly myopic eyes with varying severities of myopic atrophic maculopathy (MAM).

METHODS

The clinical records of 111 consecutive patients (158 eyes) with high myopia (refractive error ≤ -6.0 D and axial length ≥ 26.0 mm) were reviewed. Fundus photography, optical coherence tomography (OCT), and best-corrected visual acuity (BCVA) were measured. MAM was graded according to the META-analysis for Pathologic Myopia (META-PM) classification system. Myopic choroidal neovascularization (mCNV) and dome-shaped macula (DSM) were also investigated.

RESULTS

Among the 158 eyes, 18 (11%), 21(13%), 24 (15%), 25 (16%), 23 (15%), and 24 (15%) had tessellated fundus, diffuse chorioretinal atrophy, diffuse chorioretinal atrophy with DSM, patchy atrophy, patchy atrophy with DSM, and MAM with mCNV, respectively. A total of 23 (15%) eyes had macular atrophy without mCNV. Progressive thinning in the Henle's fiber and outer nuclear layers, myoid and ellipsoid zone (MEZ), outer segment (OS), and interdigitation zone and retinal pigmented epithelium based on the severity of MAM (p-value < 0.001) was found. MEZ and OS were most significantly reduced in thickness (p-value < 0.001). The presence of mCNV demonstrated significant outer retinal layer thinning compared with that of the tessellated fundus (p-value = 0.031). Patchy atrophy with DSM showed statistically poorer BCVA compared with that without (p-value = 0.008).

CONCLUSION

Visual acuity and outer retinal sublayer characteristics were correlated with the severity of MAM. Outer retinal sublayer analysis by spectrum-domain OCT shed some light on the mechanisms of MAM progression.

A Genome-Wide Association Study for Susceptibility to Axial Length in Highly Myopic Eyes

High myopia has long been highly prevalent worldwide with a largely yet unexplained genetic contribution. To identify novel susceptibility genes for axial length (AL) in highly myopic eyes, a genome-wide association study (GWAS) was performed using the genomic dataset of 350 deep whole-genome sequencing data from highly myopic patients. Top single nucleotide polymorphisms (SNPs) were functionally annotated. Immunofluorescence staining, quantitative polymerase chain reaction, and western blot were performed using neural retina of form-deprived myopic mice. Enrichment analyses were further performed. We identified the four top SNPs and found that ADAM Metallopeptidase With Thrombospondin Type 1 Motif 16 (ADAMTS16) and Phosphatidylinositol Glycan Anchor Biosynthesis Class Z (PIGZ) had the potential of clinical significance. Animal experiments confirmed that PIGZ expression could be observed and showed higher expression level in form-deprived mice, especially in the ganglion cell layer. The messenger RNA (mRNA) levels of both ADAMTS16 and PIGZ were significantly higher in the neural retina of form-deprived eyes (p = 0.005 and 0.007 respectively), and both proteins showed significantly upregulated expression in the neural retina of deprived eyes (p = 0.004 and 0.042, respectively). Enrichment analysis revealed a significant role of cellular adhesion and signal transduction in AL, and also several AL-related pathways including circadian entrainment and inflammatory mediator regulation of transient receptor potential channels were proposed. In conclusion, the current study identified four novel SNPs associated with AL in highly myopic eyes and confirmed that the expression of ADAMTS16 and PIGZ was significantly upregulated in neural retina of deprived eyes. Enrichment analyses provided novel insight into the etiology of high myopia and opened avenues for future research interest.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43657-022-00082-x.

Macular Vascularity and Ganglion Cell Complex Parameters in the Young Adults with Myopia and Progressive Myopia

Purpose

The purpose of this study is to determine the relationships between foveal avascular zone (FAZ), foveal vascular density (FD) and GCC (ganglion cell complex) parameters in a healthy myopic population using optical coherence tomography angiography (angio-OCT).

Patients and Methods

Three hundred and eighty-one eyes of 381 healthy participants were included into this study and assigned to three groups according to their spherical equivalent (SE) values and an additional progressive myopia group. One randomly chosen eye from each patient was analyzed. GCC mean thickness, focal loss of volume (FLV), global loss of volume (GLV), FAZ area, FAZ perimeter, and FD parameters were obtained with the RTVue AngioOCT device.

Results

FAZ area and its perimeter were strongly correlated with the belonging spherical equivalent group (p = 0.0001, p = 0.0008 accordingly), being the largest in progressive myopia subgroup (mean size 0.42mm²). Other factors that were significantly higher in myopic eyes were FLV (p = 0.0023), GLV (p = 0.0020). There were no differences in FD between groups. In the myopic and progressive myopia groups, there was a significant relationship between FAZ area and FLV, GLV, and GCC thickness. We found that in myopic eyes with AXL exceeding 26.6 mm, FAZ becomes negatively correlated to mean GCC thickness.

Conclusion

In myopia, compared to non-myopic groups, there is a greater loss of neural tissue represented by a thinner GCC layer, greater FLV and GLV parameters, and worse blood supply represented by a larger FAZ area. Eye axial length of 26.6 mm is a breaking point, where the negative FAZ area to GCC thickness relationship curve is getting significantly steeper.

Progression of Myopic Maculopathy: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to elucidate the risk factors for the progression of myopic maculopathy (MM) based on severity.

METHODS

In this study, we conducted a systematic review and meta-analysis of the literature published before December 2020 on the risk factors for the progression of MM in patients with pathologic myopia (PM) and high myopia (HM). Odds ratios (ORs) for different stages of myopic maculopathy categorized based on the International Meta-Analysis for PM (META-PM) classification were calculated using fixed and random effects models.

RESULTS

A total of 12,070 affected eyes derived from 5 cohort studies were included in the systematic review. The presence of PM at baseline was found to be significantly associated with an increased risk of MM progression (pooled ORs: 7.17, 95% confidence interval [CI]: 3.29-15.6), and the greater category of MM at baseline was found to be significantly associated with an increased risk of MM progression, that is, eyes with MM category 3 or more compared with eyes with MM category 2 (pooled OR: 10.95, 95% CI: 6.07-19.76) and eyes with MM category 4 compared with eyes with MM category 3 (pooled ORs: 2.45, 95% CI: 0.28-21.37).

CONCLUSIONS

The findings in this systematic review and meta-analysis indicate that the progression of MM is associated with more severe MM at baseline.

Role of Ultra-widefield Imaging in the evaluation of Long-term change of highly myopic fundus

PURPOSE

To evaluate the impact of posterior staphyloma identified using ultra-widefield fundus imaging on the long-term progression of myopic maculopathy in highly myopic patients.

METHODS

In this observational cohort study, highly myopic patients who were followed up for at least 5 years using ultra-widefield fundus imaging were analysed for fundus abnormalities and the progression of myopic maculopathy based on the International Meta-analysis of Pathologic Myopia classification.

RESULTS

This study included 390 eyes (210 patients) with the mean follow-up period of 69.2 ± 7.5 months (range, 60-88). Posterior staphyloma was identified in 198 eyes (50.8%) in the baseline ultra-widefield fundus images. The border of staphyloma was not identified within 50° view circle corresponding to conventional fundus photography in 42 eyes (21.2%) with staphyloma, most of that were wide macular type. Progression of myopic maculopathy during follow-up was observed in 202 eyes (51.8%), and eyes with staphyloma were more likely to show progression compared to those without (142/198 [71.7%] versus 60/192 [31.3%]; p < 0.001). In multivariable regression analysis, the presence of posterior staphyloma was an independent risk factor for the progression of myopic maculopathy (p = 0.005). One or more peripheral retinal lesions were observed in 302 eyes (77.4%) and 321 eyes (82.3%) in the baseline and final ultra-widefield fundus images, respectively.

CONCLUSION

Posterior staphyloma was associated with the long-term progression of myopic maculopathy. With a wider field of view, ultra-widefield fundus imaging is useful for identifying the posterior staphyloma and monitoring the progression of myopic maculopathy in highly myopic patients.

Progression and associated factors of lacquer cracks/patchy atrophies in high myopia: the Beijing Eye Study 2001-2011

PURPOSE

To assess the development and progression of lacquer cracks/patchy atrophies (LCs/PAs) in high myopia.

METHODS

The case control study included highly myopic eyes (refractive error ≤  - 6.0 diopters), examined in the population-based Beijing Eye Study 2001/2011. Using fundus photographs taken in 2001 and 2011 and optical coherence tomographic images obtained in 2011, we assessed the incidence and enlargement of pre-existing LC/PAs.

RESULTS

The study included 89 highly myopic eyes (age: 65.0 ± 9.4 years). Newly developed or enlarged LC/PAs were detected in 17 (19.1%; 95% confidence interval (CI): 11.0, 27.0) eyes, with a new LC development without previous LCs, enlargement of a pre-existing LC, LC enlargement to a PA, development of a new PA without any previous LCs, and enlargement of a pre-existing PA detected in 3, 3, 5, 3, and 3 eyes, respectively. In 14 (82.4%; 95%CI: 62.3, 100) of the 17 eyes with LC/PA development or enlargement, the LC/PAs elongated perpendicularly to, and widened in, the direction of gamma zone enlargement. Higher prevalence of LC/PA enlargement was associated (multivariable analysis) with higher myopic maculopathy stage in 2001 (odds ratio (OR): 7.83; 95%CI: 2.65, 23.2; P < 0.001) and higher frequency of parapapillary delta zone enlargement (OR: 32.0; 95%CI: 3.07, 334; P < 0.001). Prevalence of LC/PA enlargement was lower than the prevalence of changes in other myopic maculopathy features (disc-fovea distance elongation: 71%; choroidal vessel shift: 55%; reduction in ophthalmoscopical disc size: 34%; ophthalmoscopic disc size enlargement: 25%). All eyes with LC/PA enlargement showed a pre-existing and enlarging gamma zone.

CONCLUSIONS

Development and enlargement of LC/PAs were associated with enlargement of parapapillary delta zone and often occurred in association with the direction of gamma zone enlargement.

Visual Impairment and Risk of Dementia: The UK Biobank Study

PURPOSE

To investigate the relationship between visual impairment (VI) and dementia in the UK Biobank Study.

DESIGN

Prospective cohort study.

METHODS

A total of 117,187 volunteers (aged 40-69 years) deemed free of dementia at baseline were included. Habitual distance visual acuity worse than 0.3 logMAR units in the better-seeing eye was used to define VI. The incident dementia was based on electronically linked hospital inpatient and death records.

RESULTS

During a median follow-up of 5.96 years, the presence of VI was significantly associated with incident dementia (hazard ratio: 1.78; 95% confidence interval: 1.18-2.68; P = .006). There was a clear trend between the severity of VI and risk of dementia (P for trend = .002).

CONCLUSIONS

We found VI was associated with increased risk of dementia, with a progressively greater risk among those with worse visual acuity. Our findings suggested that VI might be a modifiable risk factor for dementia and highlighted the potential value of VI elimination to delay the manifestation of dementia.

Progression pattern of myopic maculopathy according to the severity of diffuse chorioretinal atrophy and choroidal thickness

This observational cohort study aimed to evaluate the progression pattern of diffuse chorioretinal atrophy (DCA) according to its severity. Highly myopic eyes with DCA were graded according to its extent in the 532-nm (green) and 633-nm (red) wavelengths images of the Optos ultra-widefield scanning laser ophthalmoscope at baseline: grade 1 and 2 were defined when increased reflectance at peripapillary region, not beyond the fovea, were observed in red laser image only and in both laser images, respectively; grade 3 and 4 were defined when increased reflectance beyond the fovea were observed in red laser image only and in both laser images, respectively. A total of 307 eyes (221 patients) were included, and progression of myopic maculopathy during follow-up of ≥ 3 years was evaluated. The mean visual acuity and subfoveal choroidal thickness (CT) differed among DCA grades (P = 0.015 and P < 0.001); a higher DCA grade had worse visual acuity and thinner choroid. During follow-up, development of patchy atrophy (PA) was observed in 3.2%, 5.5%, 12.8%, and 23.2% (P < 0.001), while changes in lacquer crack (LC) and/or development of myopic macular neovascularization were observed in 20.6%, 29.1%, 33.3%, and 15.8% (P = 0.061) of 63, 110, 39, and 95 eyes with DCA grade of 1, 2, 3, and 4 at baseline, respectively. New LC formation tended to occur in eyes with thicker CT at baseline compared to PA development and progression of pre-existing LC. In highly myopic eyes with DCA, progression pattern of myopic maculopathy is different according to its severity and CT at baseline. Grading based on separated wavelength images of ultra-widefield scanning laser ophthalmoscope is useful to evaluate the severity and prognosis of DCA in Asian patients with high myopia.

Factors Associated with Macular Staphyloma Area on Ultra-widefield Fundus Images

Purpose

To assess the feasibility of applying ultra-widefield fundus (UWF) images for macular staphyloma area (MSA) measurement and investigate the associated factors with MSA.

Methods

This is a retrospective study. MSA was measured by UWF imaging. Central foveal thickness, subfoveal choroidal thickness, subfoveal scleral thickness were measured on spectral domain optical coherence tomography. Intraclass correlation coefficients of MSA measurement would be evaluated. Multiple linear regression analysis was used to analyze the associated factors with MSA.

Results

In total, 135 eyes of 92 patients were enrolled. The mean age was 64.73 ± 10.84 years. Mean MSA on UWF image was 279.67 ± 71.70 mm². Intraclass correlation coefficients of MSA measurement was 0.965 (95% confidence interval [CI], 0.946 to 0.977; p < 0.001). In the multiple linear regression analysis, after adjusting for subfoveal choroidal thickness, best-corrected visual acuity, central foveal thickness, and subfoveal scleral thickness, the factors independently related to MSA were axial length (β = 8.352; 95% CI, 3.306 to 13.398; p = 0.001), sex (β = −26.673; 95% CI, −51.759 to −1.586; p = 0.037), age (β = 1.184; 95% CI, 0.020 to 2.348; p = 0.046).

Conclusions

It is feasible to measure MSA on UWF image. Female, longer axial length, and older age may indicate larger MSA.

Quantitative Assessment of Fundus Tessellated Density and Associated Factors in Fundus Images Using Artificial Intelligence

Purpose

This study aimed to quantitative assess the fundus tessellated density (FTD) and associated factors on the basis of fundus photographs using artificial intelligence.

Methods

A detailed examination of 3468 individuals was performed. The proposed method for FTD measurements consists of image preprocessing, sample labeling, deep learning segmentation model, and FTD calculation. Fundus tessellation was extracted as region of interest and then the FTD could be obtained by calculating the average exposed choroid area of per unit area of fundus. Besides, univariate and multivariate linear regression analysis have been conducted for the statistical analysis.

Results

The mean FTD was 0.14 ± 0.08 (median, 0.13; range, 0–0.39). In multivariate analysis, FTD was significantly (P < 0.001) associated with thinner subfoveal choroidal thickness, longer axial length, larger parapapillary atrophy, older age, male sex and lower body mass index. Correlation analysis suggested that the FTD increased by 33.1% (r = 0.33, P < .001) for each decade of life. Besides, correlation analysis indicated the negative correlation between FTD and spherical equivalent (SE) in the myopia participants (r = −0.25, P < 0.001), and no correlations between FTD and SE in the hypermetropia and emmetropic participants.

Conclusions

It is feasible and efficient to extract FTD information from fundus images by artificial intelligence–based imaging processing. FTD can be widely used in population screening as a new quantitative biomarker for the thickness of the subfoveal choroid. The association between FTD with pathological myopia and lower visual acuity warrants further investigation.

Translational Relevance

Artificial intelligence can extract valuable clinical biomarkers from fundus images and assist in population screening.

PROGRESSION OF MYOPIC MACULOPATHY IN CHINESE CHILDREN WITH HIGH MYOPIA: A Long-Term Follow-Up Study

PURPOSE

To investigate the progression of myopic maculopathy and associated factors in highly myopic Chinese children.

METHODS

In this retrospective observational case series, biometric fundus features were morphometrically measured on photographs. Myopic maculopathy was defined as recommended by the Meta-analysis of Pathologic Myopia Study Group.

RESULTS

The study included 274 children (mean age: 11.7 ± 2.5 years; mean refractive error: -7.66 ± 1.87 diopters [D]) with a mean follow-up of 4.9 ± 1.2 years. Myopic maculopathy progression was detected in 52 eyes (18.9%; 95% confidence interval [CI]: 14.3-23.7%). In multivariable analysis, myopic maculopathy progression was associated with a decrease in refractive error (odds ratio [OR]: 0.72; 95% CI: 0.56-0.92; P < 0.001) (i.e., higher myopization) and enlargement of parapapillary gamma zone (OR: 7.68; 95% CI: 1.63-36.2; P = 0.002). Incident peripapillary diffuse choroidal atrophy, noted in 47 of 236 eyes (20.0%; 95% CI: 14.8-25.2%), was correlated with a decrease in refractive error (OR: 0.70; 95% CI: 0.54-0.92; P = 0.009) (i.e., higher myopization) and greater gamma zone enlargement (OR: 8.28; 95% CI: 1.33-51.7; P = 0.02).

CONCLUSION

Myopia in schoolchildren may have a considerable risk of progressing to myopic maculopathy. Enlargement of parapapillary gamma zone was a main independent risk factor.

Longitudinal Changes in Macular Optical Coherence Tomography Angiography Metrics in Primary Open-Angle Glaucoma With High Myopia: A Prospective Study

Purpose

To characterize longitudinal changes in macular microvasculature as quantified from optical coherence tomography angiography (OCTA) metrics in primary open-angle glaucoma (POAG) eyes with and without high myopia.

Methods

In total, 63 and 61 POAG eyes with and without high myopia, respectively, underwent swept-source OCTA imaging in at least four follow-up visits at an ophthalmic center, with a scanning protocol of 3- × 3-mm centered at the fovea. The foveal avascular zone (FAZ) area, FAZ circularity, and vessel density (VD) in both the superficial (SCP) and deep capillary plexuses (DCP) were measured. The rate of change in macular OCTA metrics over time was estimated using linear mixed-effects models in both groups of POAG eyes.

Results

The mean follow-up time and number of visits were 27.72 ± 8.57 months and 8.5 (8 to 13) times, and 30.95 ± 10.19 months and 10 (8‒13) times in POAG eyes with and without high myopia, respectively. VD in the DCP reduced significantly more quickly in POAG eyes with high myopia than in those without high myopia (−5.14%/year vs. −3.71%/year, P = 0.008). Moreover, lower baseline VD in the DCP was significantly associated with faster VD reduction in POAG with high myopia eyes (P < 0.001). Conversely, the VD reduction rate in the SCP, FAZ area, and FAZ circularity in both the SCP and DCP were similar in both groups (all Ps > 0.05).

Conclusions

VD in DCP reduced significantly more quickly in POAG eyes with high myopia over time. Density in the DCP reduced more quickly when baseline VD was low.

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.

Decreased choroidal and scleral thicknesses in highly myopic eyes with posterior staphyloma

In this cross-sectional study, we investigated choroidal thickness (CT) and scleral thickness (ST) in highly myopic eyes and their associations with ocular factors. Patients underwent widefield swept-source optical coherence tomography (OCT) to measure the CT and ST at the subfovea and 3000 μm superior, inferior, temporal, and nasal to the fovea and macular curvature. A total of 237 eyes (154 patients) were included. At all five measurement points, thinner CTs and STs were associated with longer axial lengths (r = − 0.548 to − 0.357, all P < 0.001) and greater macular curvatures (r = − 0.542 to − 0.305, all P < 0.001). The CT and ST were significantly thinner in eyes with posterior staphyloma than in those without at all measurement points (all P ≤ 0.006) but did not differ between eyes with the wide macular and narrow macular type of staphyloma. Eyes with myopic maculopathy of category ≥ 3 according to the International Meta-Analysis for Pathologic Myopia classification had significantly thinner CTs and STs than those with category ≤ 2 (all P ≤ 0.005). In highly myopic eyes, a decrease in the CT and ST was more pronounced in eyes with more structural changes, such as longer axial length, steeper macular curvature, and the presence of posterior staphyloma.

Long-term progression of myopic maculopathy in degenerative myopia as imaged by SD-OCT and IR imaging

CLINICAL RELEVANCE

Clinicians can benefit from developing an understanding of the natural disease progression of myopic maculopathy in degenerative myopia using optical coherence tomography (OCT).

BACKGROUND

The prevalence of high myopia is constantly increasing. In this work, infrared imaging and OCT is used to study the natural course of the disease.

METHODS

This is a retrospective longitudinal study. Medical records of 72 patients with high myopia (< 6.00 D) and a minimum five-year follow-up period were analysed. Collected data on all enrolled patients included demographic characteristics and medical history, as well as recordings on best-corrected visual acuity, slitlamp examination, OCT, and fluorescein angiography in cases of suspected myopic choroidal neovascularisation. Images were independently marked by two graders.

RESULTS

The mean age of patients was 54.6 ± 14.4 years (59.72% female) with baseline logMAR best-corrected visual acuity of 0.22 ± 0.28. At baseline examination, 70.83% of the study group showed signs of maculopathy and 62.5% diffuse or patchy atrophy. During follow-up, 22.2% of patients with any type of atrophy showed enlarged affected areas. Two patients with baseline lacquer cracks developed new lesions. There was a weak correlation between patient age and maculopathy progression (r = 0.233; p = 0.03). While central retinal thickness was not associated with maculopathy progression (p = 0.203), a moderate correlation was found between choroidal thickness and maculopathy progression (r = -0.516; p < 0.001).

CONCLUSION

Lesion characteristics in myopic degeneration have been elucidated, taking advantage of the ongoing technological advances in retinal imaging. The understanding of disease patterns and progression is essential for appropriate management of patients, while discovering biomarkers which lead to choroidal neovascularisation development is of urgent importance to establish international diagnostic criteria and treatment protocols.

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.

Effect of medically lowering intraocular pressure in glaucoma suspects with high myopia (GSHM study): study protocol for a randomized controlled trial

Background

Currently, whether and when intraocular pressure (IOP)-lowering medication should be used in glaucoma suspects with high myopia (GSHM) remains unknown. Glaucoma suspects are visual field (VF) defects that cannot be explained by myopic macular changes or other retinal and neurologic conditions. Glaucoma progression is defined by VF deterioration. Here we describe the rationale, design, and methodology of a randomized controlled trial (RCT) designed to evaluate the effects of medically lowering IOP in GSHM (GSHM study).

Methods

The GSHM study is an open-label, single-center, RCT for GSHM. Overall, 264 newly diagnosed participants, aged 35 to 65 years, will be recruited at the Zhongshan Ophthalmic Center, Sun Yat-sen University, between 2020 and 2021. Participants will be randomly divided into two arms at a 1:1 ratio. Participants in the intervention arm will receive IOP-lowering medication, while participants in the control arm will be followed up without treatment for 36 months or until they reach the end point. Only one eye per participant will be eligible for the study. If both eyes are eligible, the eye with the worse VF will be recruited. The primary outcome is the incidence of glaucoma suspect progression by VF testing over 36 months. The secondary outcomes include the incidence of changes in the optic nerve head morphology including the retinal nerve fiber layer, and retinal ganglion cell-inner plexiform layer loss, progression of myopic maculopathy, visual function loss, and change in the quality of life. Statistical analyses will include baseline characteristics comparison between the intervention and control groups using a two-sample t-test and Wilcoxon rank sum test; generalized linear models with Poisson regression for the primary outcome; Kaplan-Meier curve and log-rank test for the incidence of the secondary outcome; and longitudinal analyses to assess trends in outcomes across time.

Discussion

To the best of our knowledge, the GSHM study is the first RCT to investigate the impact of medically lowering IOP in GSHM. The results will have implications for the clinical management of GSHM.

Trial registration

ClinicalTrials.gov NCT04296916. Registered on 4 March 2020

Choroidal thickness predicts progression of myopic maculopathy in high myopes: a 2-year longitudinal study

AIM

To prospectively determine the impact of choroidal thickness (CT) on the myopic maculopathy progression.

METHODS

This is a prospective, longitudinal, observational study. In total, 434 participants aged 7-70 years with bilateral high myopia (≤-6 D spherical error, range, -6 to -27.0 D) completed follow-up visits for 2 years. The baseline CT centred on the fovea was measured using a swept-source optical coherence tomography (OCT). Myopic maculopathy progression was determined by fundus photography. Logistic model was used to examine the impact of CT at baseline on the myopic maculopathy progression. Likelihood ratio test was adopted for model comparison.

RESULTS

The mean baseline age, spherical equivalence and subfoveal CT (SFCT) of the participants were 23.2±12.5 years, -10.50±3.18 D and 153.20±72.76 μm, respectively. Over 2-year's follow-up, 74 of 434 eyes (17.1%) had myopic maculopathy progression. Baseline SFCT was thinner in eyes with myopic maculopathy progression than those without (67.26±37.67 μm vs 170.95±65.45 μm; mean difference, 99.31 μm; 95% CI 83.61 to 115.01 μm; p<0.001). The same patterns of differences were observed in 7-18 years, 19-39 years and 40-70 years. In multivariate logistic regression model, SFCT was a significant risk factor (adjusted OR=0.97, p<0.005) when age, gender, axial length and baseline myopic maculopathy category were adjusted for. The addition of SFCT significantly improved the predictive discrimination of myopic maculopathy progression in comparison with that included established risk factors alone (area under the receiver operating characteristic curve, 0.899 vs 0.942, p<0.001).

CONCLUSION

CT is an independent predictor for myopic maculopathy progression.

Measurements of the parapapillary atrophy area and other fundus morphological features in high myopia with or without posterior staphyloma and myopic traction maculopathy

AIM

To investigate the affecting factors of parapapillary gamma and delta zones and other fundus morphological features in high myopia.

METHODS

Seventy high myopia patients were included in this retrospective observational study and 47 patients were female. Patients were divided into three groups: no posterior staphyloma (no PS), PS with myopic traction maculopathy (PS with MTM), and PS without MTM using 3-dimensional magnetic resonance imaging and optical coherence tomography. MTM patients were further classified into three types [epiretinal membrane, macular hole, and macular retinoschisis (MRS)]. Diameters of the gamma and delta zones were measured among other morphometric variables using fundus photographs.

RESULTS

Of the 70 individuals (127 eyes), the mean age was 57.46±13.56y. In univariate analysis, morphological features changed most dramatically in PS with MTM patients, who had the largest gamma zone diameters, the largest disk-fovea distance (DFD) and disk-fovea angle, and the smallest angle kappa and vertical distance of temporal arterial arcade. However, their horizontal delta zone diameter was smaller than in the patients with PS yet without MTM. In multivariate analysis, with axial length (AL) and age adjusted, the horizontal diameter in the delta zone of the PS without MTM group was still significantly larger than in the PS with MTM group (P=0.024). Comparing the three subtypes of MTM patients, the diameters of the gamma zone and DFD in MRS group were the largest.

CONCLUSION

The characteristics of the gamma and delta zones change inconsistently in different stages of high myopia. These changes may be associated with anatomical changes caused by local traction. Factors such as PS, AL and age play an important role. These findings may provide a hint about the pathogenesis of traction in high myopia.

Progression of diffuse chorioretinal atrophy among patients with high myopia: a 4-year follow-up study

AIMS

To investigate the progression pattern of diffuse chorioretinal atrophy (DCA) among Chinese participants with high myopia.

METHODS

This is a longitudinal, non-interventional study. Participants with high myopia, defined as ≤-6 diopters spherical power, were included and followed up for 4 years, and underwent cycloplegic autorefraction, best-corrected visual acuity (BCVA) and fundus photography examinations. Newly established DCA, enlargement of existing DCA and development of other lesions of myopic maculopathy were regarded as DCA progression.

RESULTS

Of the 484 participants with a mean age of 21.5±12.7 years (range, 6.8-69.7 years), 68 eyes (14.0%) showed DCA progression, with 88 lesion changes. The first appearance of DCA was identified in 21 eyes (23.9%). Of 88 eyes with DCA at baseline, 47 eyes (53.4%) showed progression, with 67 lesion changes, including 45 eyes (67.2%) with enlargement of DCA, 17 (25.3%) with a first appearance of lacquer cracks, 4 (6.0%) with development of patchy chorioretinal atrophy and 1 (1.5%) with increased numbers of lacquer cracks. Longer axial length (p<0.001), baseline DCA (p=0.005) and baseline DCA closer to the fovea (p=0.013) predicted DCA progression. Eyes had poorer BCVA at the follow-up if DCA was enlarging (p<0.001) or DCA was closer to the fovea at baseline (p=0.028) after adjusting for age,gender and cataract.

CONCLUSION

Approximately half of the participants with DCA had progression over a 4-year follow-up. Enlargement and newly developed DCA were common progression patterns. Larger areas of DCA and foveal involvement with DCA could be indicators of a worse BCVA later.