Lacquer crack lesions in pathologic myopia

Differential diagnosis of myopic choroidal neovascularization (mCNV): insights from multimodal imaging and treatment implications

PURPOSE

The aim of this article is to conduct a comprehensive systematic review about the current understandings and differential diagnosis of myopic choroidal neovascularization (mCNV) and other several similar diseases, describing their multimodal imaging analysis, prognostic implications, and current types of management.

METHODS

This systematic review was performed based on a search on the PubMed database of relevant papers regarding mCNV and other entities discussed in the paper, according to our current knowledge.

RESULTS

Through the integration of a multimodal imaging approach, especially optical coherence tomography (OCT), along with accurate demographic and clinical assessment, it becomes possible to effectively differentiate mCNV from similar yet heterogeneous entities. These conditions include macular hemorrhage due to new lacquer crack (LC) formation, inflammatory diseases such as punctate inner choroidopathy (PIC)/multifocal choroidits (MFC) and epiphenomenon multiple evanescent white dot syndrome (Epi-MEWDS), neovascular age-related macular degeneration (nAMD), idiopathic CNV (ICNV), dome-shaped macula (DSM) with subretinal fluid, retinal pigment epithelium (RPE) humps, angioid streaks (AS), choroidal rupture (CR), and choroidal osteoma (CO). Each one of these entities will be described and discussed in this article.

CONCLUSION

Myopic choroidal neovascularization is a common retinal condition, especially among young individuals. Accurate diagnosis and differentiation from similar conditions are crucial for effective treatment. Multimodal imaging, particularly OCT, plays a crucial role in precise assessment. Future research should focus on defining biomarkers and distinguishing features to facilitate prompt treatment.

Key Multimodal Fundus Imaging Findings to Recognize Multifocal Choroiditis in Patients With Pathological Myopia

Myopia represents a major socioeconomic burden with an increasing prevalence worldwide. Pathologic myopia refers to myopic patients with structural changes in the posterior pole including different patterns of chorioretinal atrophy, choroidal neovascularization (CNV) and vitreomacular tractional diseases. Multifocal choroiditis (MFC) is one of the most frequent noninfectious posterior uveitis, and epidemiologically typically affects young myopic females. Acute and chronic chorioretinal atrophic changes are the hallmark feature of MFC, with CNV developing in almost one third of cases. Thus, differentiation of inflammatory lesions due to MFC or neurodenegerative lesions due to pathologic myopic is key in order to establish a particular prognosis, follow-up schedule, and therapeutic approach. The aim of the present manuscript is to summarize and illustrate the main multimodal imaging features of these diseases.

Fundus changes in high myopia in relation to axial length of the globe

Purpose:

The aim of the study is to correlate between axial length of the eyeball and fundus changes and to know its importance.

Materials and Methods:

It was an observational study conducted for a duration of 1 year in patients with myopia more than 1 D and axial length more than 24 mm. A total of 100 eyes were included in the study and all underwent thorough fundus examination. The findings were documented using retinal maps and fundus camera photography. Data were analyzed for statistical significance using Chi-square or categorical data.

Results:

The study showed five posterior fundus changes and three peripheral fundus changes to be frequently associated with axial myopia. The five posterior fundus changes were optic disc crescents, Fuchs spot, lacquer cracks, posterior staphyloma, and chorioretinal atrophy. The three peripheral fundus changes were the area of white without pressure, lattice, and retinal breaks. Four of these lesions, i.e., crescents, posterior staphyloma, chorioretinal atrophy, and white without pressure, were found to be very highly significant with increasing axial length.

Conclusion:

Our study confirmed that there was a statistical significance in fundus changes with relation to axial length.

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.

CLINICAL FEATURES OF LACQUER CRACKS IN EYES WITH PATHOLOGIC MYOPIA

PURPOSE

To analyze the morphologic features of lacquer cracks (LCs), compare their detectability by different imaging instruments, and determine their progressive pattern.

METHODS

The medical records of 47 highly myopic eyes of 33 patients with LCs were reviewed. Fundus fluorescein angiography was used as the primary method of identifying LCs, and the detection rate was compared with that by fundus autofluorescence and optical coherence tomography.

RESULTS

A total of 176 LCs were detected in the 47 eyes. Lacquer cracks were detected more frequently in the temporal (44.3%) than the inferior (30.7%), superior (17.0%), and nasal (8.0%) quadrants of the retina. The detection rate of LCs was 98% in fundus photographs and 85% by fundus autofluorescence and optical coherence tomography. A progression of the LCs was observed in 22 of the 41 eyes with a follow-up period of ≥1 year. The progression patterns were an increase in the number (18 of 41, including 5 eyes in which new LCs had a branching pattern), elongation (4 of 41), and progression to patchy atrophy (6 of 41).

CONCLUSION

Lacquer cracks can be detected noninvasively by fundus autofluorescence and optical coherence tomography; however, improvements are necessary to detect all of the lesions. Lacquer cracks frequently progress with time, and an increase in the number of LCs was the most frequent progression pattern.

CORRELATIONS BETWEEN EXPERIMENTAL MYOPIA MODELS AND HUMAN PATHOLOGIC MYOPIA

PURPOSE

To analyze the hallmark features of pathologic myopia developed in animal models and compare them with those seen in patients.

METHODS

A literature review was performed to identify animal models that exhibited key features of pathologic myopia, namely posterior staphyloma, myopic maculopathy, lacquer cracks, and choroidal neovascularization, either spontaneously or induced by monocular deprivation. Using imaging modalities, such as optical coherence tomography, confocal scanning laser ophthalmoscopy, fluorescein angiography, and electron microscopy, these features were compared with those found in myopic maculopathy of patients.

RESULTS

Three types of animals were identified. The LRP2 knockout mice exhibited posterior staphylomas and chorioretinal atrophy at 21 and 60 days after birth, respectively. Retinopathy globe enlarged (rge) chicks and normal lid-sutured chicks developed lacquer cracks and chorioretinal atrophy. Lacquer cracks detected in rge chicks subsequently progressed to patchy chorioretinal atrophy, which is also commonly seen in patients with pathologic myopia.

CONCLUSION

The LRP2 knockout mice, retinopathy globe enlarged (rge) chicks, and normal lid-sutured chicks exhibit features typical for myopic maculopathy in patients and could serve to further elucidate the pathogenesis of myopic maculopathy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Using optical coherence tomography angiography to guide the treatment of pathological myopic patients with submacular hemorrhage

The present study aimed to investigate whether optical coherence tomography angiography (OCTA) could be used to guide the treatment of pathological myopic patients with submacular hemorrhage. Two pathological myopia patients with submacular hemorrhage were examined. Initially, choroidal neovascularization (CNV) was not observed during fundus angiography in both patients. However, based on OCTA, the first patient was diagnosed with myopic lacquer crack-related macular hemorrhage, and the second with CNV secondary to punctate inner choroidopathy. The first patient was treated with traditional Chinese medicine administered orally, and the second with intravitreal injections of anti-vascular endothelial growth factor (VEGF). Lesions in both patients were resolved. Submacular hemorrhage in pathological myopia patients could be caused by numerous mechanisms. OCTA is useful in differentiating inflammatory CNV from inflammatory lesions, particularly if CNV is not detected using other multimodal imaging techniques.

Progression of Myopic Maculopathy in Highly Myopic Chinese Eyes

Purpose

To evaluate the 2-year changes in myopic maculopathy and its associations in highly myopic eyes.

Methods

This was a longitudinal, observational cohort study involving 657 Chinese participants with bilateral high myopia (≤ -6.00 diopters spherical power), who were followed for 2 years. The worst eye of each participant was considered for the analysis. Myopic maculopathy was graded based on fundus photographs, using the International Photographic Classification and Grading System for Myopic Maculopathy.

Results

The mean baseline age was 21.6 ± 12.2 years (range, 6.8-69.7 years). Myopic maculopathy progressed in 97 (14.8%) of 657 eyes, of which 24 eyes progressed to a higher category of myopic maculopathy, including from no maculopathy to tessellated fundus in 17 eyes, from tessellated fundus to diffuse atrophy in 6 eyes, and from diffuse to patchy atrophy in 1 eye. Among 122 lesion changes identified, the most common changes were enlargement of diffuse atrophy (n = 50, 41.0%), appearance of lacquer cracks (n = 28, 23.0%), enlargement of patchy atrophy (n = 10, 8.2%) and development of additional lacquer cracks (n = 7, 5.8%). In addition, we identified 1 eye with enlargement of a Fuch's spot, and 1 eye with active choroidal neovascularization. In multiple logistic regression analysis, myopic maculopathy progression was associated with older age, longer axial length, greater change in myopic spherical equivalent and more severe myopic maculopathy at baseline.

Conclusions

Myopic maculopathy progressed in approximately 15% of highly myopic eyes over a 2-year period. Further studies with longer follow up periods are required to confirm identified risk factors for progression.

Fluorescein Leakage within Recent Subretinal Hemorrhage in Pathologic Myopia: Suggestive of CNV?

Purpose

To determine whether fluorescein leakage within subretinal hemorrhage is definitely suggestive of choroidal neovascularization (CNV) by multimodal imaging including optical coherence tomography angiography (OCTA).

Methods

Twenty-five consecutive highly myopic patients (25 eyes) with fluorescein leakage within subretinal hemorrhage detected within 1 month were prospectively included. All patients underwent OCTA and spectral-domain optical coherence tomography (SD-OCT). The OCTA and SD-OCT findings at the site of fluorescein leakage were analyzed. In cases of a doubtful diagnosis, indocyanine green angiography (ICGA) was also performed to differentiate myopic CNV from lacquer crack if necessary; all patients were followed up by SD-OCT and/or OCTA for at least 2 weeks.

Results

In terms of the site of fluorescein leakage, OCTA revealed an abnormal vascular network in the outer retina and a choriocapillaris slab in 22 out of 25 eyes (88%), which were confirmed to be CNV. However, no high-flow signal was observed in 3 of 25 eyes (12%). In these 3 cases, SD-OCT showed a focal rupture of the retinal pigment epithelium-Bruch's membrane-choriocapillaris (RPE-BM-CC) complex and a columnar hyperreflective signal of blood originating from defects with a volcanic geyser-like appearance, and no exudative signs were detected. Notably, all ruptures of the RPE-BM-CC complex were located exactly at lacquer crack sites. Moreover, with the absorption of subretinal hemorrhage, ruptures of the RPE-BM-CC complex spontaneously resolved without any intervention. Considering the multimodal imaging appearance and follow-up outcomes, these 3 eyes were eventually diagnosed as simple bleeding associated with lacquer cracks.

Conclusions

Dye leakage within recent subretinal hemorrhage on FA could be caused by new-onset lacquer cracks in pathologic myopia. Multimodal imaging including OCTA is helpful to differentiate lacquer cracks from myopic CNV.

Features of the choriocapillaris in myopic maculopathy identified by optical coherence tomography angiography

AIM

To describe the choriocapillaris features imaged by optical coherence tomography angiography (OCTA) in eyes with myopic maculopathy.

METHODS

In this retrospective, non-invasive, observational case series, 26 eyes with myopic maculopathy and 12 age-matched healthy eyes underwent fluorescein angiography, indocyanine green angiography (ICGA) (highly myopic eyes only), OCT and OCTA, and the choriocapillaris features seen on OCTA and ICGA were compared.

RESULTS

In all five (19%) eyes with patchy atrophy of the 26 highly myopic eyes, OCTA showed complete loss of the choriocapillaris and large choroidal vessels in the atrophic area. In nine (35%) eyes with diffuse atrophy in the atrophic area, OCTA showed low-density choriocapillaris in all eyes and medium and large choroidal vessels in seven (78%) eyes. In 23 eyes (88%) with lacquer cracks, OCTA showed partial loss of the choriocapillaris in 22 (96%) eyes in the area of the lacquer cracks. OCTA could not visualise the full length of the lacquer cracks in any eyes compared with ICGA.

CONCLUSIONS

OCTA visualised the choriocapillaris clearly. The choriocapillaris features differed depending to the category of myopic maculopathy. In eyes with lacquer cracks, choriocapillaris rupture might be less advanced than the breaks in Bruch's membrane and retinal pigment epithelium.

Clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization

BACKGROUND/PURPOSE

This study aims to evaluate the clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization.

METHODS

We conducted a retrospective study of 55 patients with macular coin hemorrhage who were followed for at least 3 months from January 1997 to December 2013 at Shin Kong Wu Ho-Su Memorial Hospital (Taipei, Taiwan). All patients were evaluated using fluorescein angiography and optical coherence tomography for the detection of choroidal neovascularization (CNV). We also recorded clinical characteristics such as age, sex, refractory error, and myopic fundus, to determine the relationship between CNV and non-CNV associated macular hemorrhage.

RESULTS

A total of 55 patients (30 females, 54.55%) were reviewed. The mean age was 39.7 years old. The CNV group was found to be significantly older than the non-CNV group (p < 0.05), and there was no significant difference between sex, visual acuity myopic severity, and the prevalence of fundus findings between CNV and non-CNV groups. Twenty one patients (38.18%) were found to have CNV and were all treated with intravitreal antivascular endothelial growth factor (VEGF). The other 34 patients without CNV were not treated. In both groups, the visual acuity significantly improved (anti-VEGF treated, CNV associated group, 0.7 to 0.39, p = 0.002, and untreated, non-CNV associated group, 0.56 to 0.34, p = 0.0018, respectively).

CONCLUSION

Age significantly correlated to the CNV formation in high myopia with macular hemorrhage. Favorable visual outcomes were found in pathological myopic macular hemorrhage either in the anti-VEGF treated, CNV associated group or in the untreated, non-CNV associated group.

Macular Bruch Membrane Holes in Highly Myopic Patchy Chorioretinal Atrophy

PURPOSE

Patchy atrophy is a type of chorioretinal atrophy located outside of the fovea in eyes with myopic retinopathy. Bruch membrane defects have previously been described to occur in highly myopic eyes in foveal chorioretinal atrophy associated with choroidal neovascularization (CNV). We examined whether Bruch membrane defects can be found also in patchy atrophy.

DESIGN

Retrospective observational case series.

METHODS

The study included all patients who were consecutively examined for high axial myopia (axial length ≥26.5 mm) and patchy atrophy in the study period from September to November 2015. The patients underwent a comprehensive ophthalmologic examination including swept-source optical coherence tomography (OCT) of the macula. Main outcome measures were macular Bruch membrane defects.

RESULTS

Out of 22 eyes (17 patients) with patchy atrophy, 21 eyes (96%) showed macular Bruch membrane defects, which were characterized by a lack of Bruch membrane, retinal pigment epithelium (RPE), photoreceptors, and choriocapillaris. At the edges of the macular Bruch membrane defects, the ends of the Bruch membrane were folded and the RPE was upturned. The inner retina overlying the area of the Bruch membrane defect was markedly thinned.

CONCLUSIONS

Macular Bruch membrane defects belong to the hallmarks of a type of myopic chorioretinal atrophy not associated with CNV (ie, patchy atrophy). Considering that Bruch membrane defects were also observed in myopic CNV-related foveal atrophy, macular Bruch membrane defect might be a common finding in fundus lesions related to pathologic myopia.

[Modern views on myopic maculopathy]

Most of world's scientists consider the fast-growing incidence of myopia a problem of great social importance due to associated increase in complicated myopia that leads to disability among the working-age population. This is a review on complicated myopia and myopic maculopathy that covers the history of research in this field, principles of classification, and etiological factors. It also deals with choroidal neovascularization (CNV), which often follows, and its treatment options, including anti-VEGF therapy. Possible complications of the latter are described as well. Literature search was done using PubMed, eLIBRARY, and Scopus text databases. A total of 61 sources, both Russian and foreign, were analyzed. Current clinical knowledge of different types of myopic maculopathy is still insufficient and the gaps are likely to be filled using modern methods of detailed in vivo examination of both sclera and choroidea. Anti-VEGF therapy has proved most effective in treating myopic maculopathy-associated neovascularization, however, a systematic approach to patient selection and management is yet needed.

Lacquer Cracks and Perforating Scleral Vessels in Pathologic Myopia: A Possible Causal Relationship

PURPOSE

To describe a possible causal association between the position of perforating scleral vessels and the position of lacquer cracks in eyes with pathologic myopia.

DESIGN

Retrospective case series.

METHODS

Medical records and multimodal imaging results, including confocal scanning laser ophthalmoscopy and spectral-domain optical coherence tomography, were reviewed from patients with lacquer cracks secondary to pathologic myopia who presented between 2010 and 2014 to 2 institutions. Main outcome measures were the prevalence of perforating scleral vessels at the site of the lacquer crack, the position of the lacquer crack within the macula, and the relationships between perforating scleral vessels and retinal-choroidal structures.

RESULTS

A total of 35 eyes of 30 patients with lacquer cracks were included. The average number of lacquer cracks was 1.2 ± 0.5/eye and in 37 out of 45 lacquer cracks (82%) retrobulbar vessels were found to perforate the sclera at the site of the lacquer crack. Lacquer cracks were more prevalent in the central macula (51%) than in the nasal (19%), temporal (14%), inferior (11%), and superior macula (5%) (P = .001). Transverse en face images through the area of lacquer cracks were available for 8 cases and clearly depicted the perforating vessel's course through the sclera and its termination in the choroid, directly beneath the lacquer cracks.

CONCLUSIONS

Perforating scleral vessels are often present beneath the site at which lacquer cracks form in pathologic myopia. We hypothesize that scleral expansion at the location of these perforating vessels may play a role in the formation of lacquer cracks.

Multimodal imaging including spectral-domain optical coherence tomography and confocal near-infrared reflectance for characterization of lacquer cracks in highly myopic eyes

PURPOSE

To compare multimodal imaging in detecting lacquer cracks in highly myopic eyes, and to correlate these findings with those of spectral-domain optical coherence tomography (SD-OCT).

METHODS

An observational case series study. Patients with a refractive error worse than -8 diopters and lacquer cracks were recruited. The rates of detection of the lacquer cracks using multimodal imaging including near-infrared reflectance (NIR) imaging, fundus autofluorescence (FAF) imaging, and fluorescence angiography (FA) were compared. The characteristic findings of multimodal imaging were correlated with those of SD-OCT.

RESULTS

NIR imaging was more sensitive (92.9%) in detecting lacquer cracks than either FAF (12.5%) or FA (67.9%). Lacquer cracks showed hyperreflectance on NIR, and they were consistently associated with a continuous retinal pigment epithelium-Bruch's membrane complex, thinner choroid, and acoustic shadows on SD-OCT.

CONCLUSIONS

NIR imaging is superior to blue laser light (FAF and FA) imaging in detecting lacquer cracks. SD-OCT in combination with NIR located primary pathological lacquer cracks in the intact retinal pigment epithelium-Bruch's membrane complex as well as thinner choroid. These findings indicate that multimodal cSLO and SD-OCT imaging allow for detecting of lacquer cracks in highly myopic eyes.

Myopic maculopathy imaged by optical coherence tomography: the beijing eye study

PURPOSE

To examine the features of myopia-related optical coherence tomography (OCT) findings in a population-based setting.

DESIGN

Population-based study.

PARTICIPANTS

The Beijing Eye Study 2011 included 3468 subjects with an age of 50 years or more.

METHODS

The participants underwent a detailed ophthalmic examination including OCT with enhanced depth imaging of the macula.

MAIN OUTCOME MEASURES

Optical coherence tomography features of the macula in highly myopic eyes defined by a refractive error of -6 diopters or less or an axial length of 26.5 mm or more.

RESULTS

Readable OCT images were available for 6530 eyes (94.5%) of 3278 participants. The most common change in the macula was maculoschisis (0.8±0.1%), followed by incomplete posterior vitreous detachment (0.7±0.1%), disruption of the photoreceptor inner segment/outer segment interface (0.6±0.1%), epiretinal membranes (0.6±0.1%), macular defects in Bruch's membrane (0.3±0.1%), clumping of the retinal pigment epithelium (0.2±0.1%), vitreofoveal adhesion (0.2±0.1%), and macular holes in 2 eyes (0.1±0.1%). Prevalence of any myopic maculopathy per eye was 112 of 6530, or 1.71±0.16% (95% confidence interval [CI], 1.40-2.03). After adjustment for longer axial length (P<0.001; odds ratio [OR], 2.68; 95% CI, 1.97-3.64) and myopic refractive error (P<0.001; OR, 0.63; 95% CI, 0.55-0.73), presence of any myopic maculopathy was not significantly associated with any systemic variables (all P≥0.05), including biochemical blood examination and ocular parameters. Best-corrected visual acuity was associated significantly with the absence of a disruption of the photoreceptor inner segment/outer segment interface (P<0.001), epiretinal membranes (P<0.001), and macular holes (P<0.001) after adjustment for age and cylindrical refractive error.

CONCLUSIONS

Based on OCT examination, the most common macular change in highly myopic eyes was maculoschisis, followed by incomplete posterior vitreous detachment, disruption of the photoreceptor inner segment/outer segment interface, epiretinal membranes, macular defects in Bruch's membrane, clumping of the retinal pigment epithelium, vitreofoveal adhesion, and macular holes. The most important macular changes with a negative effect on best-corrected visual acuity were a disruption of the photoreceptor inner segment/outer segment interface and epiretinal membranes.

Choroidal thickness measurement in myopic eyes by enhanced depth optical coherence tomography

PURPOSE

To measure choroidal thickness (CT) in myopic eyes using enhanced depth imaging (EDI).

DESIGN

A cross-sectional study.

PARTICIPANTS

Fifty-six consecutive patients with spherical equivalent refractive error of at least 6 diopters (D) were evaluated.

METHODS

Enhanced depth imaging optical coherence tomography (OCT) images were obtained by positioning the spectral-domain OCT device close enough to the eye to acquire an enhanced signal of the choroidal layer. Choroidal depth was measured as the distance between the outer reflective retinal pigment epithelium (RPE) layer and the inner sclera border. Measurements were made in a horizontal fashion across the fovea at 500-μm intervals of the sections. The CT was measured at the subfoveal region in a horizontal fashion, 3 mm temporal to fovea and 3 mm nasal to fovea.

MAIN OUTCOME MEASURES

Correlations among CT with age, refractive error in diopters, and visual acuity in logarithm of the minimum angle of resolution (logMAR) were analyzed with linear mixed models.

RESULTS

The mean age of the 56 patients was 50.4 years (± 2.03 years standard deviation; interquartile range [IQR], 42-62 years), and the mean refractive error was -8.7 D (IQR, -6.1 to -11 D). The mean subfoveal CT was 118 μm (± 68 μm) and correlated negatively with age (P = 0.032) and refractive error (P = 0.011). Regression analysis suggested that subfoveal CT decreased by 11.9 μm for each decade of life and by 6.205 μm for each diopter of myopia. The subfoveal CT was inversely correlated with the logMAR visual acuity (P = 0.008), and visual acuity improved by 0.02 (logMAR) in a 10-μm increase in CT.

CONCLUSIONS

Choroidal thickness decreases with age and severity of myopia. Visual acuity decreases in line with decreasing subfoveal CT. A reduction in CT is related to aging and the severity of myopia, whereas visual acuity depends on subfoveal CT. Our study supports the theory that choroidal abnormality may play a key role in the pathogenesis of myopic degeneration.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Choroidal thickness and biometric markers for the screening of lacquer cracks in patients with high myopia

Objectives

Validation of choroidal thickness and other biometrics measured by spectral domain optical coherence tomography (SD-OCT) in predicting lacquer cracks formation in highly myopic eyes.

Methods

Patients with a refractive error worse than −8 diopters and moderate myopic maculopathy were recruited into two groups based on the presence or absence of lacquer cracks (36 eyes without and 33 eyes with lacquer cracks). Choroidal thickness, refractive error, and axial length were measured and subjected to receiver operating characteristic curve analysis to identify the optimal cutoff values at predicting lacquer crack formation. The width of the retinal pigment epithelium (RPE), RPE to the inner segment/outer segment line, RPE to the external limiting membrane were also measured and compared to the subfoveal choroidal thickness to assess their relationships as potential markers of lacquer crack formation.

Results

Lacquer crack is associated with decreased choroidal thickness, lower best-corrected visual acuity, longer axial length and higher refractive errors. Choroidal thickness has the strongest association with lacquer crack formation versus axial length and refractive error. In eyes with lacquer cracks, stellate lacquer cracks are associated with thinner choroidal thickness compared to eyes with linear lacquer cracks. Subfoveal choroidal thickness less than the width of the retinal pigment epithelium to the inner segment/outer segment line is also associated with lacquer crack formation (sensitivity 78.8%, specificity 88.3%, and accuracy 81.2%).

Conclusions

This study suggests that choroidal thickness and other SD-OCT measurements could be employed clinically to predict the development and severity of lacquer cracks in patients with high myopia.

Myopia-related optic disc and retinal changes in adolescent children from singapore

PURPOSE

To examine early myopia-related optic disc and retinal changes in a Singapore Chinese adolescent sample without confounding ocular or systemic disease.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Children aged 12 to 16 years at a follow-up visit for Singapore Cohort Study of Risk Factors for Myopia.

METHODS

Detailed eye examinations, including cycloplegic autorefraction and contact biometry, were performed. Retinal photographs were acquired using nonmydriatic retinal photography among children who attended follow-up examinations in 2006, and were graded for myopia-related optic disc signs and macular changes by a single experienced grader. Optic nerve head parameters were measured adjusting for camera and ocular magnification with appropriate formulae.

MAIN OUTCOME MEASURES

Optic disc changes (tilt, beta peripapillary atrophy [β-PPA], and optic nerve parameters) and macular changes (staphyloma, lacquer cracks, Fuchs' spot, and chorioretinal atrophy).

RESULTS

Retinal photography data were available for 1227 children (median age, 14 years; range 12-16). Tilted optic discs were found in 454 subjects (37%), and were associated with myopic spherical equivalent refractions (-3.6 diopters [D] vs -1.3 D; P<0.0001), higher cylindrical error (0.9 vs 0.7 D; P = 0.0001) and longer axial length (24.93 vs 23.96 mm; P<0.0001). The pattern of distribution of the axes of the tilted discs and corneal curvature were similar (P = 0.4). All linear optic nerve parameters, except vertical disc diameter (P = 0.15), were significantly smaller in eyes with than without tilted discs (P <0.001) after adjusting for confounders. Apart from 20 cases, all eyes with tilted optic discs had associated β-PPA. We identified only 1 case each (0.1% prevalence) of staphyloma and lacquer cracks in this sample.

CONCLUSIONS

In this Asian adolescent population, tilted optic discs were highly prevalent, in contrast with the lower prevalence reported in Caucasian populations. Eyes with tilted discs tended to have smaller optic cups with smaller cup-to-disc ratios, and were associated with myopic refraction, higher astigmatism, and longer axial length. There were similar patterns of distribution between the axis of disc tilt and the axis of corneal curvature, which could have embryologic origins. In contrast with optic disc changes, myopic macular changes were rare in this age group, suggesting that these changes may develop later in life.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Prevalence and progression of myopic retinopathy in Chinese adults: the Beijing Eye Study

PURPOSE

To determine the prevalence and progression of myopic retinopathy in Chinese adults.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

The Beijing Eye Study 2001 included 4439 subjects of 5324 individuals who were invited to participate (response rate, 83.4%); the eligibility criterion was an age of 40+ years. The study was repeated in 2006, with 3251 subjects (73.2%) participating.

METHODS

The participants underwent a detailed eye examination, including fundus photography. Myopic retinopathy was defined by posterior staphylomata, lacquer cracks, Fuchs' spot of the macula, and myopic chorioretinal atrophy at the posterior pole. Parapapillary atrophy was assessed separately.

MAIN OUTCOME MEASURES

Prevalence of myopic retinopathy and its change during a follow-up of 5 years.

RESULTS

After exclusion of pseudophakic or aphakic eyes, and eyes without assessable fundus photographs, 4319 subjects (97.3%) were included in the present study. Myopic retinopathy was present in 198 eyes (2.3%+/-0.2%; 95% confidence interval [CI], 2.0-2.6) of 132 participants (3.1%). Myopic retinopathy was significantly associated with higher age (P<0.001), worse best-corrected visual acuity (P<0.001), deeper anterior chamber (P = 0.04), larger optic disc (P<0.001), less age-related macular degeneration (P = 0.02; odds ratio [OR] 0.90), and greater prevalence of open-angle glaucoma (P<0.001; OR 4.42). Myopic retinopathy was not associated significantly (P>0.20) with body height and weight, gender, rural versus urban region of residence, level of education, intraocular pressure, or central corneal thickness. The prevalence of myopic retinopathy increased significantly (P<0.001) with increasing myopic refractive error, from 3.8% in eyes with a myopic refractive error of < -4.0 diopters to 89.6% in eyes with a myopic refractive error of at least -10.0 diopters. At the 5-year follow-up examination, enlargement of the chorioretinal atrophy at the posterior fundus was observed in 9% of the eyes.

CONCLUSIONS

Myopic retinopathy was present in 3.1% of subjects aged 40+ years who resided in the Greater Beijing area. Myopic retinopathy was associated with increased age, worse best-corrected visual acuity, deeper anterior chamber, larger optic disc, less age-related macular degeneration, and higher prevalence of open-angle glaucoma.

Enhanced depth imaging optical coherence tomography of the choroid in highly myopic eyes

PURPOSE

To measure macular choroidal thickness (CT) in highly myopic eyes using enhanced depth imaging optical coherence tomography (OCT).

DESIGN

Retrospective, observational case series.

METHODS

Enhanced depth imaging OCT images were obtained in highly myopic eyes (> or =6 diopters [D]). Images of CT were obtained by positioning a spectral-domain OCT device close enough to the eye to acquire an inverted image. CT was measured from the outer border of the retinal pigment epithelium to the inner scleral border at 1000-mum intervals of a horizontal section from 3 mm temporal to the fovea to 3 mm nasal to the fovea. Statistical analysis was performed to evaluate CT at each location and to correlate CT with age and refractive error.

RESULTS

The mean age of the 31 patients (55 eyes) was 59.7 years (+/- 17.6 years; range, 24 to 90 years), and the mean refractive error was -11.9 D (+/- 3.7 D). The mean subfoveal CT was 93.2 microm (+/- 62.5 microm) and was correlated negatively with age (P = .006), refractive error (P < .001), and history of choroidal neovascularization (P = .013). Regression analysis suggested that subfoveal CT decreased by 12.7 mum for each decade of life and by 8.7 microm for each D of myopia.

CONCLUSIONS

The choroid in highly myopic eyes is very thin and undergoes further thinning with increasing age and degree of myopia. Abnormalities of the choroid may play a role in the pathogenesis of myopic degeneration.

Traitement des néo-vaisseaux choroïdiens rétrofovéolaires du myope fort par photothérapie dynamique : résultats à 1 an et à 2 ans

PURPOSE

To evaluate the visual outcome of photodynamic therapy with verteporfin in patients with subfoveal choroidal neovascularization (CNV) caused by pathologic myopia.

METHODS

Retrospective and noncomparative analysis of 42 patients with CNV secondary to pathologic myopia recruited between September 2001 and 2003, who were treated with a standard regimen of photodynamic therapy with verteporfin.

RESULTS

Forty-two patients were followed up for 12 months; 15 out of 42 completed 24 months of follow-up. Initial visual acuity ranged from 1/10 to 5/10 with a mean of 1.6/10. Twenty-five (56.7%) eyes had stable or improved visual acuity at 12 months with a mean of 2.5/10. In the group of patients who completed 24 months of follow-up, six eyes (39.9%) had stable or improved visual acuity with a mean of 1.6/10 at 1 year and 1.25/10 at 2 years. The average photodynamic therapy treatment required in 1 and 2 years were 1.5 and 2.1, respectively, and they are less than those reported by the Verteporfin in Photodynamic Therapy (VIP) study.

CONCLUSION

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization caused by pathologic myopia maintained a visual benefit at 1 and 2 years.

Prognostic factors influencing visual outcome of photodynamic therapy for subfoveal choroidal neovascularization in pathologic myopia

PURPOSE

To examine the influence of age, lesion size, degree of myopia, and baseline visual acuity on the visual outcome of patients with pathologic myopia and choroidal neovascularization (CNV) who received photodynamic therapy (PDT) with verteporfin.

DESIGN

Retrospective, noncomparative consecutive case series.

METHODS

Forty-three eyes of 41 patients were treated in a two-year time span; 36 eyes of 36 patients who had received PDT for CNV due to pathologic myopia were examined for the above-mentioned factors 24 months after first treatment. All patients had been treated according to the Verteporfin in Photodynamic Therapy (VIP) study criteria. Patients were examined in two- to three-month intervals with Snellen visual acuity, biomicroscopy, and fluorescein angiography.

RESULTS

Baseline visual acuity and age were both prognostic factors for visual outcome (P =.0097, P =.0055). Lesion size (greatest linear dimension) at baseline, refractive error, or the number of treatments had no influence on the outcome.

CONCLUSION

Age and baseline visual acuity have an effect on visual outcome in patients receiving PDT due to CNV secondary to pathologic myopia. Younger patients and patients with higher baseline visual acuity had a better treatment outcome.

Spontaneous Lacquer Crack Lesions in the Retinopathy, Globe Enlarged (rge) Chick

Lacquer crack lesion (LCL), a complication of myopia in human patients, is characterized by loss of retinal pigment epithelium and breaks in Bruch's membrane. This report describes comparable lesions in the "retinopathy, globe enlarged" (rge) chick. Twenty-six birds, (nine rge/rge [affected], 12 rge/+ [carriers] and five +/+ [normal]), were examined ophthalmoscopically from hatching up to 336 days of age. Ophthalmoscopically detected fundus lesions were investigated by light and transmission electron microscopy. Pale, linear fundus lesions were detected in both eyes of seven of the nine rge/rge chicks, from as early as 45 days of age. Histological and ultrastructural examination of four of the affected rge/rge chicks revealed areas of ruptured Bruch's membrane, with focal absence of retinal pigment epithelium. Fibroblasts covered the interface of the abnormal Bruch's membrane and choriocapillaris. There was disorganization of overlying photoreceptor outer and inner segments, and thinning of inner and outer nuclear layers, while the rest of the inner retina appeared unaltered. The lesions present in rge chicks showed histological changes similar to those of LCLs described in human patients with pathological myopia. The formation of LCLs in rge chicks is probably due to stretching of Bruch's membrane secondary to abnormal globe enlargement, resulting in linear rupture of the membrane and associated changes. The rge chick may prove a useful model for human LCL formation.

Prevalence and progression of myopic retinopathy in an older population

OBJECTIVE

To determine the prevalence and progression of myopic retinopathy in an older community-based population sample.

DESIGN

Population-based epidemiologic study.

PARTICIPANTS

Eligible residents aged 49 years or older (n = 3654) who attended the Blue Mountains Eye Study, west of Sydney, Australia.

METHODS

Participants had a detailed eye examination including measurement of logarithm of the minimum angle of resolution (logMAR) visual acuity, standardized refraction, and retinal stereophotography. All patients were invited to attend follow-up examinations after 5 years.

MAIN OUTCOME MEASURES

Myopic retinopathy was defined to include staphyloma, lacquer cracks, Fuchs' spot and myopic chorioretinal atrophy. beta-peripapillary atrophy was assessed separately.

RESULTS

Signs of myopic retinopathy were found in 67 eyes from 44 participants (1.2%), a prevalence of 1.4% in women and 1.0% in men; this increased from 1% in right eyes with myopia <3 diopters to over 50% in right eyes with myopia > or =9 diopters. There was a nonsignificant age-related trend in prevalence. The average spherical equivalent refraction was -6.1 diopters and the average visual acuity was 20/40 in eyes with myopic retinopathy. Visual impairment (<20/40) was present in 38.8% of affected eyes. Myopic retinopathy was bilateral in 52% of cases. Staphyloma was present in 26 participants (0.7%), bilateral in 35%, with a strong concordance of staphyloma location. Lacquer cracks were seen in 8 participants (0.2%), Fuchs' spot in 3 (0.1%), and chorioretinal atrophy in 7 (0.2%). Forty-six eyes (68.7%) with myopic retinopathy were reexamined after 5 years; 8.7% had new or increased numbers of lacquer cracks and 15.2% had new or expanded areas of chorioretinal atrophy. In those eyes developing lacquer cracks or chorioretinal atrophy, best-corrected visual acuity decreased by a mean of two LogMAR lines.

CONCLUSIONS

This study documented the age and sex-specific prevalence of myopic retinopathy and 5-year progression in an older white population.

Optical coherence tomography of choroidal neovascularization in high myopia

AIM

To investigate morphologic changes in the eye with choroidal neovascularization (CNV) in high myopia using optical coherence tomography (OCT).

METHODS

Optical coherence tomography was performed in 35 patients (42 eyes) with myopic CNV. Myopic CNV was divided into active, scar, or atrophic stages based on funduscopic and fluorescein angiographic findings. The characteristics of OCT findings in each stage were identified.

RESULTS

In the active stage (11 eyes), OCT clearly displayed a neovascular membrane as a highly reflective dome-like elevation above the retinal pigment epithelium (RPE). No apparent subretinal fluid accumulation around the CNV was identified. In the scar stage (12 eyes), only the surface of the CNV showed high reflectivity, which was markedly attenuated below the surface. In the atrophic stage (19 eyes), the CNV had become totally flat and chorioretinal atrophy around the regressed CNV showed high reflectivity.

CONCLUSIONS

Optical coherence tomography demonstrated characteristic features at each stage of myopic CNV. Optical coherence tomography appears to be useful in evaluating the stage and activity of myopic CNV.

Myopia and contrast sensitivity function

PURPOSE

to measure the contrast sensitivity function of varying degrees of myopia with two types of optical correction (spectacle lens and contact lens).

METHODS

One hundred and five myopic eyes and twenty-eight emmetropic eyes were collected. The myopic group included 105 eyes corrected with spectacle lenses and 71 eyes of them corrected with contact lenses, too; all had corrected vision acuity of 20/20 or better. The myopic eyes were divided into four groups: group 1 (-1D to -3D), low myopia; group 2 (-3.25D to -6D), medium myopia; group 3 (-6.25D to -12D), high myopia; and group 4 (> -12D), severe myopia. Spatial contrast sensitivity was measured using the OPTEC 2000 Contrast Sensitivity System.

RESULTS

In groups 1 and 2, no statistically significant difference was found between myopes and emmetropes. In group 3, statistically significant loss of contrast sensitivity at higher spatial frequencies was found for myopic subjects corrected with spectacle lens, but not for myopes corrected with contact lens. In group 4, myopic subjects corrected with spectacle lenses showed significantly reduced contrast sensitivity function at all spatial frequencies; subjects corrected with contact lenses showed statistical sensitivity losses at 6, 12, 18 cycle/degree spatial frequencies.

CONCLUSIONS

1. We may suppose that low and medium myopes (groups 1 and 2), who showed normal contrast sensitivity functions, had no retinal dysfunction. 2. For high myopes, contact lens correction could reduce optical defocus and improve contrast sensitivity function in high spatial frequencies. 3. As retinal function disturbances occurred in severe myopes, the diminished contrast sensitivity was not fully compensated by contact lens correction. 4. Loss of contrast sensitivity might be interpreted as evidence for early retinal function disruption before retinal pathological events occur in severe myopes.

Colour vision and dark adaptation in high myopia without central retinal degeneration

Colour vision and dark adaptation of 36 high myopes (68 eyes) without degenerative fundus changes were studied with the standard pseudoisochromatic plates part 2, Farnsworth-Munsell 100 hue (FM 100) test, Nagel anomaloscope, colour vision meter 712-anomaloscope, and Goldmann-Weekers adaptometer. The ages of the myopes ranged from 20 to 49 years, the visual acuity from 6/12 to 6/6, and the refractions from -6.0 to -20.0 D. All the colour vision tests and dark adaptation examination gave normal results. However, the error scores of the myopes in (blue) box III of the FM 100 test were significantly higher than those of the controls matched for age. In dark adaptation, the rod thresholds of the myopes were significantly higher than in the controls. The stretching of the posterior pole of the eye might explain this minimal impairment of the photoreceptor layer of the retina without any visible degenerative changes in the fundus.

Visual performance in high myopia

The visual performances of eight low myopic subjects (-2 D to -7 D) and eight high myopic subjects (greater than -7 D) with normal visual acuities were analyzed by contrast sensitivity testing with both spectacle and contact lens corrections to determine if any differences in function exist between those groups. Statistically significant (p = 0.0382) contrast sensitivity losses, particularly at the higher spatial frequencies, were found for the high myopic subjects when corrected with spectacles. However, with contact lens correction, no statistically significant overall difference between the two groups was evident (p = 0.5083). We believe that these results confirm for highly myopic subjects the lack of any consistently present loss of resolution. The differences with spectacle correction are attributable to the nature of the optical correction.

Subretinal hemorrhages with or without choroidal neovascularization in the maculas of patients with pathologic myopia

We examined 20 patients (24 eyes) who had refractive errors of -8 diopters or more and subretinal hemorrhages at the initial visit. They were divided into two groups according to fluorescein angiographic findings: 15 eyes without choroidal neovascularization (CNV) and 9 eyes with CNV. Subretinal hemorrhage without CNV was frequent in patients aged 20-39 years (mean, 36.8 years). CNV was common in patients aged 60-79 years (mean, 61.0 years). No relationship was noted between refractive error and type of hemorrhage. In the eyes without CNV, the subretinal hemorrhages disappeared spontaneously after a few months. The visual acuity of these patients was variable at the initial visit (range, 0.01-0.8), and was unchanged or improved during the follow-up period. In the eyes with CNV, the visual acuity was less than 0.1 at the initial visit and was unchanged or worse during the follow-up period.

Choroidal neovascularization

Choroidal neovascularization is now considered to be a most important feature in the pathogenesis and treatment of a number of chorioretinal disorders. Since the recognition of its importance, choroidal neovascularization has been described in clinical and pathologic studies of a variety of different ophthalmologic conditions. We have summarized the diseases in which choroidal neovascularization occurs and have reviewed studies on the natural history, clinical findings, and therapy of choroidal neovascularization that provide the basis for the current management of this condition.

Natural history of choroidal neovascularization in degenerative myopia

We studied 354 eyes with myopic chorioretinal degeneration by means of standard clinical evaluation and fluorescein angiography. The eyes were classified on the basis of the degree of chorioretinal degeneration found in the posterior pole. Lacquer cracks (breaks in Bruch's membrane) were noted in 82% of the 149 eyes with choroidal neovascular membranes (CNM) and in 96% of the 58 eyes with isolated subretinal hemorrhages. These hemorrhages were reabsorbed without adverse visual sequelae in 32 eyes that were followed; in 14 of these eyes that were followed closely, the average time of reabsorption was 6.4 weeks. Seventy eyes with CNM were followed for an average of 40.9 months. In 96% of these eyes the CNM remained stable or regressed, leaving an atrophic, nonexudative scar. This study indicates that CNM in degenerative myopia is usually self-limited.

Subretinal neovascularisation in eyes with localised inferior posterior staphylomas

We report seven cases of subretinal neovascularisation with inferior posterior staphyloma. The upper border of the shallow staphyloma, detected by B-mode echography, invaded the macular area, and there was a neovascular net at the edge of the staphyloma. Three of the cases showed chorioretinal atrophy at the upper edge of the staphyloma in the same location as the neovascular net. Our cases were identical to those of subretinal neovascularisation in high myopic eyes in which the rupture of Bruch's membrane was related to the deformity of the scleral shell. As our cases included not-high-myopic eyes, the results suggest that the identical mechanism might be involved in the occurrence of neovascular maculopathy in the pathological high myopic eye and in the not-high-myopic eye with posterior staphyloma. Localised inferior posterior staphyloma may be an important cause of 'idiopathic' subretinal neovascularisation.

Punctate inner choroidopathy

Ten moderately myopic women had blurred vision, light flashes, or paracentral scotomas associated with small yellow-white lesions of the inner choroid and pigment epithelium. Most lesions had an overlying serous detachment, were hyperfluorescent, and leaked fluorescein during the acute phase. The lesions healed into atrophic scars and became progressively more pigmented with time. Subretinal neovascular membranes later developed from scars in six patients. Vision was usually only minimally affected unless the lesions were subfoveal or unless choroidal neovascular membranes subsequently occurred. Extensive laboratory studies were noncontributory.

Pathologic myopia and choroidal neovascularization

In 14 of 27 eyes with choroidal neovascular membranes associated with severe myopia, visual acuity deteriorated two or more lines on the Snellen chart. Twelve of the 27 eyes became legally blind. Final visual acuity may be related to the position of the neovascular membrane within the posterior pole. Four of the eight eyes with new vessels outside of the foveal avascular zone had follow-up visual acuities of 6/12 (20/40) or better. Only one of five eyes with new vessels extending to the edge of the avascular zone had a final visual acuity of 6/12 (20/40) or better. Three of 14 eyes with a neovascular membrane beneath the foveal avascular zone had visual acuities of 6/12 (20/40) or better. Neovascularization associated with severe myopia clearly jeopardizes central visual acuity. Laser photocoagulation therapy may be useful in treating neovascular membranes outside the foveal avascular zone or extending to the edge of the perifoveal capillary network. A larger prospective study is needed to determine the guidelines for and efficacy of such treatment for patients with severe myopia who develop choroidal neovascularization.

Physiologic vs pathologic myopia: genetics vs environment

Physiologic myopia occurs as the result of a correlation failure of refraction components in the normal eye. Pathologic myopia is caused by excessive axial elongation that primarily involves the ora-equatorial area and the posterior pole. Peripheral fundus changes and posterior staphyloma formation are ophthalmoscopic evidences of this process. Heredity is the basic determinant of ocular refraction, but numerous agents produce both temporary and permanent myopias.