Natural course of myopic traction maculopathy and factors influencing progression and visual acuity

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.

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.

Retinal and Vitreous Changes Associated with Spontaneous Improvement in Myopic Macular Schisis

PURPOSE

To describe the retinal and vitreous changes in eyes showing myopic macular schisis (MMS) improvement when vitrectomy was not performed and identify triggering factors.

DESIGN

Retrospective observational study.

SUBJECTS

Patients with nonoperated MMS.

METHODS

The records of patients with MMS who were followed without performing surgery for >6 months were retrospectively reviewed, and the eyes showing an anatomic improvement were included. Myopic macular schisis evolution was analyzed quantitatively (central foveal thickness [CFT], parafoveal thickness, maximum height) and qualitatively (presence/absence of foveal detachment, lamellar hole, epiretinal membrane, choroidal neovascularization, inner and outer retinoschisis, vitreous status) at baseline and at the final visit. An anatomic improvement was defined as a decrease in CFT by ≥50 μm.

MAIN OUTCOME MEASURES

The rate of anatomic improvement of MMS without performing vitrectomy and the morphological changes observed in these cases.

RESULTS

In a cohort of 74 nonoperated eyes with MMS, MMS improved in 14 eyes (19%) after a mean follow-up of 55 ± 38 months (range, 8-138). In these improved cases, the mean decrease in CFT was 153 ± 166 μm (range, 24-635; P = 0.005) and a complete resolution of MMS was observed in 9 eyes (64%). In 9 eyes (64%), the improvement was associated with visible vitreous changes in the macular area on the OCT scans. The mean visual acuity, which was already good at baseline (20/50, 0.4 ± 0.2 logarithm of the minimum angle of resolution), increased at the last visit (20/40, 0.3 ± 0.3 logarithm of the minimum angle of resolution) but without reaching significance.

CONCLUSIONS

This long-term follow-up analysis showed that almost 20% of MMS in eyes without indication for surgery could improve over time. In most cases, the improvement was associated with an apparent resolution of vitreous tensions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Choroidal Perfusion Changes After Vitrectomy for Myopic Traction Maculopathy

BACKGROUND

The choroidal vasculature supplies the outer retina and is altered in many retinal diseases, including myopic traction maculopathy (MTM). Choroid health is typically assessed by measuring the choroidal thickness; however, this method has substantial limitations. The choroidal vascularity index (CVI) was recently introduced to provide quantitative information on the vascular flow in the choroid. This index has been evaluated in a wide range of diseases but has not been extensively used to characterize MTM.

AIM

This study aimed to investigate the CVI across different stages of MTM and the influence of macular surgery on choroidal perfusion markers in different surgically resolved MTM stages.

METHODS

Eighteen healthy myopic eyes in the control group and forty-six MTM eyes in the surgical group were evaluated using enhanced optical coherence tomography (OCT) imaging. Binarized OCT images were processed to obtain the luminal choroidal area (LCA) and stromal choroidal area (SCA), which were used to calculate CVI in the form of a percentage ratio. CVI data were collected at baseline, one and four months postoperatively, and at the final clinical visit. MTM eyes were divided into four stages based on disease severity. The choriocapillaris flow area (CFA) and central subfield thickness (CSFT) were measured along side the CVI.

RESULTS

No significant differences were observed between the two groups at baseline, except for visual acuity (p  < 0.0001). Surgery significantly improved vision at all postoperative time points (p  < 0.0001). At baseline, there were no significant differences in CVI, CFA, or CSFT scores between the control and surgical groups. However, all three measurements were lower at the final visit in the surgical group (p ≤0.0001). No significant differences were found in any of the parameters among the four stages of MTM (p  > 0.05). Ultimately, correlation and multivariate linear regression analyses did not reveal any significant association between CVI and visual acuity.

CONCLUSIONS

This study did not find significant preoperative differences in CVI between healthy myopic eyes and eyes with MTM. However, the postoperative CVI and CFA values were significantly lower than those of the control eyes. Thus, CVI may not be a good biomarker for surgical outcomes, as the correlation between CVI and visual acuity was not statistically significant.The CVI and CFA decreased after surgery, providing evidence of choroidal changes after surgical management.

Visualized analysis of research on myopic traction maculopathy based on CiteSpace

AIM

To analyze the global scientific output concerning myopic traction maculopathy (MTM) and to summarize the research frontiers and hot topics of MTM related researches.

METHODS

Data were collected for bibliometric and visualization analyses from Web of Science (WOS) Core Collection. Exported records were analyzed for titles, publication years, research institutions, journal names, authors, keywords, and abstracts using CiteSpace software version 6.1.

RESULTS

A total of 839 related studies were analyzed, the publication volume increased annually, with Asia the most active region of MTM research. Optical coherence tomography angiography, optical coherence tomography, macular hole, high myopia, macular buckling were identified as the focus of the current research. Progression, association, classification and shape were identified as the major research frontiers.

CONCLUSION

MTM is a major cause of visual loss in pathological myopic eyes. During the preceding 17y, the number of annual publications in MTM research increased gradually. Studies on the progression nature of MTM, genome-wide association study and proper classification of MTM might still be the frontiers of MTM researches.

Multimodal Analysis on Clinical Characteristics of the Advanced Stage in Myopic Traction Maculopathy

INTRODUCTION

Here we investigate the clinical features of foveal detachment (FD), full-thickness macular hole (MH), and macular hole retinal detachment (MHRD) in myopic traction maculopathy (MTM).

METHODS

In the retrospective observational case series, 314 eyes of 198 patients with myopic retinoschisis in Beijing Tongren Hospital were enrolled. We recorded gender, age, and axial length and evaluated fundus characteristics using optical coherence tomography. Epiretinal membranes (ERMs), vitreoretinal traction, and paravascular abnormalities (PVAs) were used to describe the vitreoretinal interface condition. Different retinoschisis layers (inner, middle, and outer retinoschisis) and the location with a range of outer retinoschisis were evaluated to reveal the retinal condition. Five patterns of the scleral shape: dome-shaped, sloped toward the optic nerve, symmetrical or asymmetrical around the fovea, and irregular were assessed to show retina-sclera condition. We regarded the FD, full-thickness MH, and MHRD as the advanced stage in MTM. Multivariate logistic regression assessed significant factors for the advanced stage with odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

There were 76 eyes with FD, 6 eyes with full-thickness MH, and 7 eyes with MHRD. The mean age was 52.9 ± 12.3 years. On univariate analysis, the eyes with the advanced stage were older and had higher rates of ERMs, PVAs, middle retinoschisis, outer retinoschisis, and irregular sclera shape. The number of retinoschisis layers and the grade of outer retinoschisis were higher in eyes with the advanced stage. After multivariate logistic regression, ERMs (OR 1.983; 95% CI 1.093-3.595; P = 0.024), middle retinoschisis (OR 2.967; 95% CI 1.630-5.401; P < 0.001), and higher grades of outer retinoschisis (OR 2.227; 95% CI 1.711-2.898; P < 0.001) remained associated with the advanced stage.

CONCLUSION

ERMs, middle retinoschisis, and more extensive outer retinoschisis were significant characteristics of the advanced stage in MTM.

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.

LONG-TERM EVOLUTION OF MYOPIC RETINOSCHISIS WITH A DOME-SHAPED MACULA AND PREDICTORS OF PROGRESSION AND VISUAL PROGNOSIS

PURPOSE

To study the long-term natural course of myopic retinoschisis (MRS) with a dome-shaped macula (DSM) and to identify the factors affecting its development and visual prognosis.

METHODS

In this retrospective case series study, we followed 25 MRS eyes with a DSM and 68 MRS eyes without a DSM for at least two years and observed changes in optical coherence tomography morphologic features and best-corrected visual acuity.

RESULTS

During the mean follow-up of 48.3 ± 13.24 months, the difference in the rate of MRS progression between the DSM and non-DSM groups was not significant ( P = 0.7462). In the DSM group, the patients whose MRS progressed were older and had a higher refractive error than those whose MRS was stable or improved ( P = 0.0301 and 0.0166, respectively). The patients whose DSM was located in the central fovea had a significantly higher progression rate than those whose DSM was located in the parafovea ( P = 0.0421). For all DSM eyes, BCVA did not decrease significantly in eyes with extrafoveal retinoschisis ( P = 0.2500), patients whose best-corrected visual acuity decreased more than two lines had a greater central foveal thickness initially than those whose best-corrected visual acuity decreased less than two lines during the follow-up period ( P = 0.0478).

CONCLUSION

A DSM did not delay the progression of MRS. The development of MRS in DSM eyes was associated with age, myopic degree, and DSM location. A higher schisis cavity predicted visual deterioration, and a DSM protected visual function in extrafoveal MRS eyes during the follow-up period.

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.

The Role of Widefield and Ultra Widefield Optical Coherence Tomography in the Diagnosis and Management of Vitreoretinal Diseases

Background: This study reports on the advantages of wide-field (WF)- and ultra-widefield (UWF)- optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in managing different vitreoretinal diseases in a real-life setting using the new WF—Swept Source (SS)—OCT Xephilio S1 (Canon, Tokyo, Japan). Methods: We conducted an observational retrospective case series study involving 1472 eyes that underwent retinal scans with Canon Xephilio^® OCT-S1 between 1 March 2021 and 1 December 2021 at Eyecare Clinic (Brescia, Italy). All patients underwent routine ophthalmologic examinations along with WF and UWF color fundus retinography with Clarus 500™ (Carl Zeiss Meditec, Inc., Dublin, CA, USA) and Xephilio^® OCT-S1. WF SS-OCT, UWF-OCT, WF-OCTA, and UWF-OCTA were taken by using Xephilio^® OCT-S1. Results: We analyzed 122 peripheral retinal lesions, 144 retinal detachment, 329 high myopic eyes, 37 pediatric cases, 60 vascular retinopathies, 15 choroidal lesions, and 90 eyes as follow-up post vitreoretinal surgery. The OCT-S1 was the only reliable and diagnostic exam for peripheral lesions, pediatric and high myopic cases, and significantly influenced the management in 10% of cases and the postoperative follow-up. Conclusions: WF and UWF OCT and OCTA imaging may help in the management of several vitreoretinal diseases, becoming an indispensable tool for the high-quality management of patients.

Value of Combining Optical Coherence Tomography with Fundus Photography in Screening Retinopathy in Patients with High Myopia

Objective

To explore the value of combining optical coherence tomography (OCT) with fundus photography in screening retinopathy in patients with high myopia.

Methods

By means of retrospective study, 40 high myopia patients with retinopathy treated in our hospital from January 2020 to January 2021 were selected as the study group, and 40 healthy individuals in the same period were included in the control group. All patients received traditional ophthalmic examination, and accepted fundus fluorescence imaging, OCT, and fundus photography examination step by step by the same operator. After that, three physicians read the slides by the double blind method, and took the results of fundus fluorescence imaging as the gold standard to analyze the diagnostic efficacy of OCT, fundus photography and their combination.

Results

The clinical data and examination results showed that no statistical differences in general data including patients' mean age, gender ratio, and educational degree between the study group and the control group were observed (P > 0.05), and the nerve thickness above/below the optic disk and temporal/nasal nerve thickness of the optic disk of the study group were significantly different from those of the control group (P < 0.001); the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of diagnosis of combining OCT with fundus photography were respectively 95.0%, 97.5%, 97.4%, 95.1%, and 96.3%, which were significantly higher than OCT or fundus photography alone (P < 0.05); and for combined examination, AUC (95%CI) = 0.963 (0.000–1.000).

Conclusion

Combining OCT with fundus photography can effectively identify high myopia patients with retinopathy, which is conducive to improving clinical positive ratio and providing objective basis for treatment.