Association between high myopia and progression of visual field loss in primary open-angle glaucoma

Glaucoma Progression in Treatment-Naïve Patients With Normal Tension Glaucoma With Myopia-Role of Intraocular Pressure

PRCIS

While myopia has been recognized as a positive prognostic factor for normal tension glaucoma (NTG) progression in the adult population, some myopic NTG eyes exhibited significant progression within 2 years when left untreated, even under low intraocular pressure (IOP).

OBJECTIVE

To determine the natural history and risk factors associated with progressive retinal nerve fiber layer (RNFL) thinning in previously stable, treatment-naïve, patients with NTG with myopia.

METHODS

This study included 111 myopic NTG eyes without IOP-lowering treatment for at least 1 year and without disease progression during the treatment-free period. The RNFL thickness was measured, and a visual field test was performed every 6-12 months for >2 years. Patients with progressive changes were classified as the P(+) group, whereas those without progression were classified as the P(-) group. Cox proportional hazards model assessed risk factors of progression, whereas linear regression determined factors associated with the rate of RNFL thinning.

RESULTS

Progressive change was observed in 25 of the 111 participants [P(+) group, 22.5%]. A family history of glaucoma, higher mean IOP, and maximum IOP during the follow-up were significant factors both for being in the P(+) group and for a faster RNFL thinning. None with a mean IOP <11 mm Hg were in the P(+) group. Davies test identified that 14.2 mm Hg was a significant breakpoint ( P = 0.042), above which the rate of RNFL thinning increased significantly with the mean IOP ( R2 = 0.252, P = 0.034).

CONCLUSIONS

Patients with myopic NTG untreated for IOP, especially those with a family history of glaucoma or higher IOP, are at increased risk of progression. Early treatment initiation is advised for high-risk patients with myopic NTG, even when their condition appears stable.

Assessing Glaucoma Severity and Progression in Individuals with Asymmetric Axial Length: An Intrapatient Comparative Study

PURPOSE

To investigate whether a difference exists in intereye glaucoma severity and progression in patients with asymmetric axial length.

DESIGN

Long-term observational study.

PARTICIPANTS

Patients older than 20 years with a diagnosis of glaucoma at Seoul National University Hospital, Seoul, Korea, between 2010 and 2020.

METHODS

Patients with a diagnosis of glaucoma in both eyes with an axial length difference of more than 1.0 mm were included. Each individual's eyes were classified into longer eye and shorter eye, and the baseline and follow-up clinical data were analyzed using the paired T-test and McNemar test.

MAIN OUTCOME MEASURES

Differences in clinical characteristics in patients with asymmetric axial length.

RESULTS

A total of 190 eyes of 95 patients with glaucoma with asymmetric axial length were included in the study. The patients' mean age was 51.2 ± 12.3 years, and the mean follow-up period was 10.1 ± 3.9 years. No difference was found in baseline intraocular pressure (IOP) or central corneal thickness between longer eyes and shorter eyes. Among the baseline disc parameters, ovality index, β-zone and γ-zone parapapillary atrophy (PPA) area were larger (P < 0.001) in the longer eyes. In the baseline OCT data, the retinal nerve fiber layer (RNFL) thickness (P = 0.009) and ganglion cell-inner plexiform layer (GCIPL) thickness (P < 0.001) were thinner in the longer eyes. According to a baseline visual field (VF) test, the mean deviation and VF index (VFI) values were significantly lower (P < 0.001, P = 0.034) in the longer eyes. Based on an analysis of glaucoma progression, the rate of change of superior GCIPL (longer eyes, -0.65 μm/year; shorter eyes, -0.40 μm/year), mean deviation (longer eyes, -0.40 dB/year; shorter eyes, -0.21 dB/year), and VFI (longer eyes, -0.92%/year; shorter eyes, -0.46%/year) were larger (P = 0.006, P = 0.005, P < 0.001) in the longer eyes. Additionally, the greater the difference in IOP fluctuation, the greater the difference in the rate of change between mean deviation and VFI.

CONCLUSIONS

When an axial length difference of more than 1.0 mm was present, glaucoma tended to be more severe and to progress faster in the longer eyes.

FINANCIAL DISCLOSURE(S)

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

Implications of optic disc rotation in the visual field progression of myopic open-angle glaucoma

PURPOSE

To investigate the relationship between the characteristics of optic disc rotation and visual field (VF) progression in patients with myopic open-angle glaucoma (OAG).

METHODS

We included 53 eyes from 53 myopic OAG patients who were followed-up over a 3-year period. The characteristics of optic disc rotation including the degree of optic disc rotation, direction of optic disc rotation, and optic disc rotation-VF defect correspondence were investigated. The rates of global and regional VF progression were compared with different characteristics of optic disc rotation.

RESULTS

Thirty-seven eyes (69.8%) showed inferior optic disc rotation and 41 (77.4%) eyes showed optic disc rotation-VF defect correspondence. The inferiorly rotated optic discs with corresponding superior VF defect had faster VF progression in the superior peripheral region (P = 0.028) and superiorly rotated optic discs with corresponding inferior VF defect had faster VF progression in the inferior peripheral region (P = 0.031). The VF progression was restricted to the superior hemifield in the eyes with inferiorly rotated optic discs and corresponding superior VF defects.

CONCLUSION

In myopic OAG patients, the direction of optic disc rotation might predict faster VF progression in the corresponding peripheral region.

Progress in clinical characteristics of high myopia with primary open-angle glaucoma

High myopia (HM) is a significant risk factor for the occurrence and progression of primary open-angle glaucoma (POAG). Identification with POAG in the HM population is an emergent challenge. Patients with HM have a significantly higher probability of complicating POAG than those without HM. When HM is associated with POAG, the changes to the fundus caused by both of them are confused with each other, making the diagnosis of early glaucoma difficult. This article reviews available researches on HM with POAG, summarizing the characteristics of the fundus structure such as epidemiology, intraocular pressure, optic disc, ganglion cell layer, retinal nerve fiber layer, vascular density, and visual field.

Factors Associated with Large Cup-to-Disc Ratio and Blindness in the Primary Open-Angle African American Glaucoma Genetics (POAAGG) Study

BACKGROUND/AIMS

Primary open-angle glaucoma (POAG) disproportionately affects individuals of African ancestry. In these patients' eyes, a large cup-to-disc ratio (LCDR > 0.90) suggests greater retinal ganglion cell loss, though these patients often display varied visual ability. This study investigated the prevalence and risk factors associated with LCDR in African ancestry individuals with POAG and explored the differences between blind (>20/200) and not blind (≤20/200) LCDR eyes.

METHODS

A case-control methodology was used to investigate the demographic, optic disc, and genetic risk factors of subjects in the Primary Open-Angle African American Glaucoma Genetics Study. Risk factors were analyzed using univariable and multivariable logistic regression models with inter-eye correlation adjusted using generalized estimating equations.

RESULTS

Out of 5605 eyes with POAG, 1440 eyes (25.7%) had LCDR. In the multivariable analysis, LCDR was associated with previous glaucoma surgery (OR = 1.72), increased intraocular pressure (OR = 1.04), decreased mean deviation (OR = 1.08), increased pattern standard deviation (OR = 1.06), thinner retinal nerve fiber layer (OR = 1.05), nasalization of vessels (OR = 2.67), bayonetting of vessels (OR = 1.98), visible pores in the lamina cribrosa (OR = 1.68), and a bean-shaped cup (OR = 2.11). Of LCDR eyes, 30.1% were classified as blind (≤20/200). In the multivariable analysis, the statistically significant risk factors of blindness in LCDR eyes were previous glaucoma surgery (OR = 1.72), increased intraocular pressure (OR = 1.05), decreased mean deviation (OR = 1.04), and decreased pattern standard deviation (OR = 0.90).

CONCLUSIONS

These findings underscore the importance of close monitoring of intraocular pressure and visual function in African ancestry POAG patients, particularly those with LCDR, to preserve visual function.

Influence of Trabeculectomy with Mitomycin C on Longitudinal Changes in the Visual Field in Glaucoma Patients with High Myopia

Purpose

To evaluate the effect of trabeculectomy (Trab MMC) on visual field (VF) progression in eyes with glaucoma and high myopia.

Patients and Methods

Patients diagnosed with primary open-angle glaucoma or exfoliation glaucoma who underwent Trab MMC as the first glaucoma surgery along with ≥3 VF tests preoperatively and postoperatively were enrolled. High myopia was defined as an axial length ≥26.5 mm. Postoperative reductions in intraocular pressure (IOP) were assessed by survival analysis using IOP measurements obtained preoperatively. The longitudinal trends of the outcome measures were evaluated using linear mixed models.

Results

Thirty-five eyes of 32 patients were included in this study, including 22 eyes of 20 patients in non-highly myopic group and 13 eyes of 12 patients in highly myopic group. IOP decreased after Trab MMC, and the survival rate did not differ significantly in relation to axial length. Linear mixed-model analyses suggested that the inhibitory effects of Trab MMC on the rate of mean deviation (MD) changes were significant in the non-highly myopic group (-0.53 ± 0.15 dB/year preoperatively to -0.16 ± 0.13 dB/year postoperatively; P = 0.004), but not in the highly myopic group (-0.66 ± 0.19 dB/year preoperatively to -0.48 ± 0.18 dB/year postoperatively; P = 0.32).

Conclusion

Trab MMC reduced IOP in both highly myopic and non-highly myopic eyes, and IOP reduction was very similar in both groups. The VF deterioration rate decreased in both groups, but the change was weaker and nonsignificant in the highly myopic group.

Visual field progression in open-angle glaucoma after refractive corneal ablation surgery

This study aimed to investigate visual field (VF) progression in open-angle glaucoma (OAG) subjects who had a history of refractive corneal ablation surgery (RCAS). Retrospective study. The medical records of 21 subjects who had a history of refractive corneal ablation surgery (RCAS group) and 36 patients who had myopia without a history of RCAS (non-RCAS group) were reviewed. VF progression was determined by the non-parametric progression analysis (NPA) method. VF progression and clinical characteristics were compared between the two groups. For the RCAS group, refractive regressions were analysed. The mean follow-up periods were 4.5 years and 5.5 years for the RCAS and non-RCAS groups, respectively. More glaucoma subjects in the RCAS group (57.1%) had likely VF progression than in the non-RCAS group (25.0%) (p = 0.01). The RCAS group had a significantly lower percentage of IOP reduction with anti-glaucoma medication than the non-RCAS group (p = 0.037). Eyes with likely VF progression had a higher incidence of refractive regression (91.7%, 11/12) than eyes without it (33.3%, 3/9). Among subjects whose eyes had refractive regression, 78.6% (11/14) had likely VF progression, and 21.4% (3/14) did not (p = 0.016). The VF progression in OAG after RCAS was faster than that of myopic OAG without RCAS. Anti-glaucoma treatment should be actively enhanced in clinical practice.

The Anterior Segment Biometrics in High Myopia Eyes

INTRODUCTION

The aim of this study was to investigate and compare the anterior segment biometrics in high myopia and control groups.

METHODS

Thirty-four eyes of 34 high myopia patients and 42 eyes of 42 control subjects were included. Schlemm's canal (SC) area, trabecular meshwork (TM) thickness and length, scleral spur (SS) length, and anterior scleral thickness (AST) were measured using swept-source optical coherence tomography. Associations between SC area, TM thickness, TM length, SS length, and AST were also estimated.

RESULTS

SC area, TM thickness, and SS length were significantly associated with AST0 (AST at 0 mm from SS) in both high myopia and control groups. AST0 (702.61 ± 78.05 vs. 729.12 ± 95.87 μm, p = 0.085) and SS length (206.25 ± 52.25 vs. 212.09 ± 51.86 μm, p = 0.556) were not significantly different between high myopia and control groups, whereas SC area (6,622.68 ± 1,130.06 vs. 6,105.85 ± 1,297.84 μm2, p = 0.015) was significantly greater and TM thickness (96.15 ± 34.40 vs. 107.93 ± 29.97 μm, p = 0.048) was significantly thinner in high myopia group than in control group.

CONCLUSION

SC area and TM thickness were significantly associated with AST0, while AST0 and SS length were not significantly different between high myopia and control groups. The changes in SC and TM dimensions in high myopia eyes might be caused by factors other than AST0 and SS length.

Degree of Myopia and Glaucoma Risk: A Dose-Response Meta-analysis

PURPOSE

To verify the dose-response relation between the degree of myopia and open-angle glaucoma (OAG) risk DESIGN: Dose-response meta-analysis.

METHODS

We searched the PubMed, EMBASE, and Cochrane Library databases for population-based studies published until November 30, 2020, and reporting on both myopia and OAG. Random-effect models generated pooled odds ratios (OR) and 95% CIs. Results robustness was confirmed by influence and subgroup analyses. A 2-stage dose-response meta-analysis calculated the OAG risk per unit dose of myopia (spherical equivalent [SE] decrease of 1 diopter [D]) and examined the relationship pattern.

RESULTS

The meta-analysis comprised 24 studies in 11 countries (514,265 individuals). The pooled OR of any myopia degree's association with OAG was 1.88 (95% CI, 1.66-2.13; I² = 53%). The OR differences based on ethnicity (Asians vs Westerners) or 5 geographic areas were not statistically significant (P = .80 and P = .06, respectively). The pooled ORs of the associations between low, moderate, moderate-to-high, high myopia, and OAG were 1.50 (95% CI, 1.29-1.76), 1.69 (95% CI, 1.33-2.15), 2.27 (95% CI, 1.74-2.96), and 4.14 (95% CI, 2.57-6.69), respectively. According to the dose-response meta-analysis, the pooled OR (per SE 1-D change) was 1.21 (95% CI, 1.15-1.28). The OAG risk accelerated at approximately -6 D, and further accelerated from -8 D, showing a nonlinear concave upward slope (P = .03).

CONCLUSIONS

For each unit (1-D) increase in myopia, the risk of glaucoma increases by approximately 20%. The risk more steeply increases in high-degree myopia, representing a significant nonlinear relationship.

The Association between Myopia and Primary Open-Angle Glaucoma: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies identified myopia as a risk factor for primary open-angle glaucoma (POAG). However, recent studies have shown different results, the definitive relationship between myopia and POAG remains controversial.

OBJECTIVES

To investigate the relationship between myopia and POAG.

METHODS

Published articles were searched from PubMed, Embase, and Scopus databases between 1970 and 2020. A pooled analysis of the ORs was performed using a random-effects model.

RESULTS

Data on the association between myopia and POAG, were obtained from 16 cross sectional studies, and the pooled OR was 2.26 (95% confidence interval [CI], 1.77 - 2.89, P < 0.001) in random effects model (I2 = 86%; P < 0.01). For the relationship of myopia and POAG progression, data from seven longitudinal cohort studies were included and the pooled OR was 0.85 (95% CI, 0.73 - 0.99, P = 0.042) in the random-effects model (I2 = 88%; P < 0.01).

CONCLUSION

Our findings demonstrated that myopia may be a risk factor associated with POAG and a possible protective factor for POAG progression. It may due to myopia with the presence of a lamina cribrosa defect slow down the visual field loss also POAG progression, further research for underlying mechanisms is still needed.

The Relationship Between Optic Disc and Retinal Artery Position and Glaucomatous Visual Field Progression

Purpose

To investigate whether retinal structural parameters, including positions of the optic disc and major retinal arteries, affect glaucomatous progression of the visual field (VF).

Methods

In this cohort study, 116 eyes of 73 patients with primary open angle glaucoma (POAG) were included. VFs were measured using the Humphrey Field Analyzer 24-2 program and the VF was divided into seven sectors according to the corresponding optic disc angle. Average total deviation (TD) was calculated in each sector. Positions of major retinal arteries in the superotemporal and inferotemporal areas were decided by identifying the points where the retinal artery intersected the 3.4-mm-diameter circle around the optic disc. The relationship between sectorial TD VF progression rate and eight variables (age, mean and standard deviation of intraocular pressure during the observation period, baseline sectorial TD value, papillomacular bundle tilt angle, and axial length, along with superior/inferior arterial angle) was investigated.

Results

The main outcome measures were the association between retinal structural parameters and glaucomatous progression of VF. The superior retinal artery angular position was positively associated with sectorial TD progression rates in two central sectors in the inferior hemifield, which suggests faster VF progression where superior retinal artery angles are narrow. Papillomacular bundle tilt was not associated with TD progression rate in any sector.

Conclusions

Progression of the inferior VF was associated with the superior retinal artery angular position in this study of POAG.

Longitudinal Evaluation of the Structural and Functional Changes Associated with Glaucoma in Myopia

SIGNIFICANCE

This study ascertains that myopia is a risk factor for glaucoma progression among eyes with primary open angle glaucoma. Myopic eyes with primary open angle glaucoma may benefit from measurement and incorporation of axial length information into clinical decision making.

PURPOSE

The purpose of this study was to estimate the rate of change in retinal nerve fiber layer (RNFL) thickness and the rate of change in visual field of glaucoma patients with and without myopia.

METHODS

We conducted a prospective, observational cohort study where we analyzed 245 eyes of 135 glaucoma patients followed for a mean period of 6.08 years. All the subjects had RNFL imaging and standard automated perimetry performed for both eyes in the same visit every 4 months for at least 60 months.

RESULTS

The rate of change of average RNFL thickness and visual field index (VFI) was -0.29 μm/y (95% confidence interval, -1.80 to +1.23 μm/y) and -0.30%/y (95% confidence interval, -2.24 to +1.64%/y), respectively, after adjusting for age, axial length, IOP, baseline RNFL thickness, signal strength, and correlation between fellow eyes. Axial length, as a continuous variable, was not associated with the rates of change of average RNFL thickness and VFI. However, high myopic eyes with axial lengths of ≥26.0 and ≥26.5 mm had an average rate of change of RNFL thickness of 0.15 and 0.16 μm/y faster than eyes with axial lengths of less than 26 and 26.5 mm, respectively. Similarly, myopic eyes with an axial length of ≥26.5 mm were associated with a 0.21%/y faster rate of VFI reduction.

CONCLUSIONS

Both RNFL and visual field progression rates are faster in myopic glaucomatous eyes with an axial length of ≥26.5 mm than in eyes <26.5 mm. However, the small difference that supports high myopia as a risk factor for progression does not indicate the clinical importance or significance of axial length.

The Complications of Myopia: A Review and Meta-Analysis

Purpose

To determine the risk between degree of myopia and myopic macular degeneration (MMD), retinal detachment (RD), cataract, open angle glaucoma (OAG), and blindness.

Methods

A systematic review and meta-analyses of studies published before June 2019 on myopia complications. Odds ratios (OR) per complication and spherical equivalent (SER) degree (low myopia SER < -0.5 to > -3.00 diopter [D]; moderate myopia SER ≤ -3.00 to > -6.00 D; high myopia SER ≤ -6.00 D) were calculated using fixed and random effects models.

Results

Low, moderate, and high myopia were all associated with increased risks of MMD (OR, 13.57, 95% confidence interval [CI], 6.18-29.79; OR, 72.74, 95% CI, 33.18-159.48; OR, 845.08, 95% CI, 230.05-3104.34, respectively); RD (OR, 3.15, 95% CI, 1.92-5.17; OR, 8.74, 95% CI, 7.28-10.50; OR, 12.62, 95% CI, 6.65-23.94, respectively); posterior subcapsular cataract (OR, 1.56, 95% CI, 1.32-1.84; OR, 2.55, 95% CI, 1.98-3.28; OR, 4.55, 95% CI, 2.66-7.75, respectively); nuclear cataract (OR, 1.79, 95% CI, 1.08-2.97; OR, 2.39, 95% CI, 1.03-5.55; OR, 2.87, 95% CI, 1.43-5.73, respectively); and OAG (OR, 1.59, 95% CI, 1.33-1.91; OR, 2.92, 95% CI, 1.89-4.52 for low and moderate/high myopia, respectively). The risk of visual impairment was strongly related to longer axial length, higher myopia degree, and age older than 60 years (OR, 1.71, 95% CI, 1.07-2.74; OR, 5.54, 95% CI, 3.12-9.85; and OR, 87.63, 95% CI, 34.50-222.58 for low, moderate, and high myopia in participants aged >60 years, respectively).

Conclusions

Although high myopia carries the highest risk of complications and visual impairment, low and moderate myopia also have considerable risks. These estimates should alert policy makers and health care professionals to make myopia a priority for prevention and treatment.

Impact of myopia on the association of long-term intraocular pressure fluctuation with the rate of progression in normal-tension glaucoma

BACKGROUND/AIMS

To investigate whether the association of long-term intraocular pressure (IOP) fluctuation with the rate of progression of normal-tension glaucoma (NTG) differs between myopia and non-myopia.

METHODS

The medical records of 65 myopic NTG (axial length (AL) > 24.0 mm) and 64 non-myopic NTG eyes (AL < 24.0 mm), who had been treated with topical medications for more than 5 years, were reviewed. Multiple linear regression models were fitted to analyse the relationships of the slope of mean deviation (MD) or visual field index (VFI) with the clinical factors, including the interactions with myopia.

RESULTS

The average follow-up period was 8.3 years. Twenty-two (22) non-myopic eyes (34.4%) and 27 myopic eyes (41.5%) showed NTG progression (p=0.511). The interaction of myopia with IOP fluctuation was a significant factor regarding both MD and VFI slope (p=0.002, 0.024, respectively); stratified analyses suggested that the risk effect of IOP fluctuation was significant only in myopic NTG in terms of both MD (β= -1.27, p=0.003) and VFI slope (β=-2.32, p=0.011).

CONCLUSION

Long-term IOP fluctuation was significantly related to faster visual field progression in myopic NTG eyes, compared with non-myopic NTG eyes.

Determining Possible Shared Genetic Architecture Between Myopia and Primary Open-Angle Glaucoma

Purpose

To determine genetic correlations between common myopia and primary open-angle glaucoma (POAG).

Methods

We tested the association of myopia polygenic risk scores (PRSs) with POAG and POAG endophenotypes using two studies: the Australian & New Zealand Registry of Advanced Glaucoma (ANZRAG) study comprising 798 POAG cases with 1992 controls, and the Rotterdam Study (RS), a population-based study with 11,097 participants, in which intraocular pressure (IOP) and optic disc parameter measurements were catalogued. PRSs were derived from genome-wide association study meta-analyses conducted by the Consortium for Refractive Error and Myopia (CREAM) and 23andMe. In total, 12 PRSs were constructed and tested. Further, we explored the genetic correlation between myopia, POAG, and POAG endophenotypes by using the linkage disequilibrium score regression (LDSC) method.

Results

We did not find significant evidence for an association between PRS of myopia with POAG (P = 0.81), IOP (P = 0.07), vertical cup-disc ratio (P = 0.42), or cup area (P = 0.25). We observed a nominal association with retinal nerve fiber layer (P = 7.7 × 10-3) and a significant association between PRS for myopia and disc area (P = 1.59 × 10-9). Using the LDSC method, we found a genetic correlation only between myopia and disc area (genetic correlation [RhoG] = -0.12, P = 1.8 × 10-3), supporting the findings of the PRS approach.

Conclusions

Using two complementary approaches we found no evidence to support a genetic overlap between myopia and POAG; our results suggest that the comorbidity of these diseases is not influenced by common variants. The association between myopia and optic disc size is well known and validates this methodology.

The Longitudinal Danish High Myopia Study, Cohort 1948: at age 66 years visual ability is only occasionally affected by visual field defects

PURPOSE

A descriptive study on visual fields, as part of a 50-year follow-up of high myopia in an unselected cohort-based Danish sample, now aged 66 years.

METHODS

In a Copenhagen 1948 birth cohort (n = 9243), 39 individuals aged 14 years were identified with myopia of at least -6 D, and with regular clinical follow-ups since then. In 2002 (n = 34, age 54 years) and 2008 (n = 32, age 60), the individual ambulatory visual field was outlined by kinetic Goldmann large object perimetry (IV or V,4e). At age 66 years, 28 attended for the 2014-2015 follow-up, at which smaller Goldmann objects (II and I,4e) were added, further to identify relative defects.

RESULTS

Repeated large object perimetry disclosed statistically significant general peripheral narrowing over the 12-13-year test period, though slight and without practical implications. Two new cases showing absolute defects were however added to the three already known. The addition of small Goldmann objects disclosed relative defects in another eight participants, in some to suggest a refraction-related pattern (fundus ectasia; uncorrected high myopia). However, comparing eyes with and without defects, statistical importance could not be attached to the degree of myopia, fundus ectasia or optic disc morphology (χ² , n.s.).

CONCLUSION

(i) Serial large object Goldmann isopters over the 'senior' decade up to age 66 demonstrated a slight general peripheral narrowing by age of visual fields in high myopia. (ii) Overall 42% of the participants had absolute or relative defects (in 5 and 8, respectively), however, without socio-visual consequences when binocular. (iii) Visual field loss by age still appears a minor issue in clinically unselected high myopia.

Physical exercise and glaucoma: a review on the roles of physical exercise on intraocular pressure control, ocular blood flow regulation, neuroprotection and glaucoma-related mental health

The benefits of physical exercise on health and well-being have been studied in a wide range of systemic and ocular diseases, including glaucoma, a progressive optic neuropathy characterized by accelerated apoptosis of retinal ganglion cells (RGCs). Elevated intraocular pressure (IOP) and insufficient ocular perfusion have been postulated to be the two main theories in glaucoma development and progression. The effects of exercise in these two aspects have been demonstrated by numerous researches. A review in 2009 focusing on these two theories concluded that exercise results in transient IOP reduction but an inconsistent elevation in ocular perfusion. However, the majority of the studies had been conducted in healthy subjects. Over the past decade, technological advancement has brought forth new and more detailed evidence regarding the effects of exercise. Moreover, the neuroprotective effect of exercise by upregulation of neurotrophin and enhancement of mitochondrial function has been a focus of interest. Apart from visual impairment, the mental health issues in patients with glaucoma, which include anxiety and depression, should also be addressed. In this review, we mainly focus on publications from the recent years, so as to provide a comprehensive review on the impact of physical exercise on IOP, ocular perfusion, neuroprotection and mental health in patients with glaucoma.

Correlation between central corneal thickness and myopia

PURPOSE

To analyze the correlation between central corneal thickness (CCT) and myopia in refractive surgery candidates.

MATERIALS AND METHODS

Patients that underwent myopic laser refractive surgery between January 2000 and December 2014 were included. Preoperative CCT was measured by ultrasonic pachymetry, and refractive status determined by manifest and cycloplegic refraction.

RESULTS

A total of 30,245 individuals were included. Mean age was 28.2 ± 8.6 years, and 45.9% were female. Mean refractive error was 4.02 ± 2.17 D (range 0.25-19.5), and the mean CCT measurement was 533.5 ± 35.5 µm (range 404-794). Younger individuals showed higher degree of myopia (p = 0.006). No difference in CCT was found between women and men (533.0 ± 35.1 and 533.6 ± 35.9 µm, respectively, p = 0.19). Though CCT showed no correlation with age (p = 0.226) participants above age 40 expressed higher CCT values (p < 0.001). No significant correlation was found between the CCT and cylinder (p > 0.05). An increase in mean keratometry was associated with a decrease in CCT (p < 0.001). There was a direct correlation between the degree of myopia and CCT (r = 0.94, p < 0.001). The result remained the same after adjusting for age group and gender in stepwise backward regression analysis (p < 0.001).

CONCLUSION

Central corneal thickness is correlated with the degree of myopia among adults undergoing refractive surgery.

Intereye comparison of ocular factors in normal tension glaucoma with asymmetric visual field loss in Korean population

PURPOSE

To identify ocular parameters corresponding to asymmetric visual field (VF) loss in normal tension glaucoma (NTG) through intereye comparisons.

PATIENTS AND METHODS

Medical records of NTG patients with asymmetric and symmetric VF losses were retrospectively reviewed. The criterion for asymmetry in VF was 6 dB difference of mean deviation. Refractive error, intraocular pressure (IOP), central corneal thickness, ovality index, and peripapillary atrophy (PPA)/disc area ratio were obtained from each patient. Intereye comparison was performed for asymmetric group, symmetric group, and myopic and nonmyopic asymmetric subgroups.

RESULTS

We included 155 patients; 110 patients in asymmetric group and 45 patients in symmetric group. In intereye comparison for total asymmetric group, refractive error (P = 0.006), initial IOP (P = 0.001), ovality index (P = 0.008), and PPA (P < 0.001) were significantly asymmetric. For myopic subgroup, refractive error (P = 0.004), ovality index (P = 0.001), and PPA (P = 0.003) were significant factors. For nonmyopic subgroup, initial IOP (P = 0.003) and PPA (P = 0.007) were significant factors. Symmetric group showed no significant difference between the eyes. Multivariate analysis demonstrated that refractive error (P = 0.002) and PPA (P = 0.028) were significant factors in myopic subgroup, and initial IOP (P = 0.022) and PPA (P = 0.002) were significant factors in nonmyopic subgroup.

CONCLUSIONS

In this intereye comparison, the more myopic eye in myopic NTG patient, and the more pressured eye in nonmyopic NTG patient demonstrated more severe VF loss. Myopic and nonmyopic patients may follow different pathophysiologic processes. Discriminative attentions should be paid to NTG patients by subtypes.

A single gene connects stiffness in glaucoma and the vascular system

Arterial calcification results in arterial stiffness and higher systolic blood pressure. Arterial calcification is prevented by the high expression of the Matrix-Gla gene (MGP) in the vascular smooth muscle cells (VSMC) of the arteries' tunica media. Originally, MGP, a gene highly expressed in cartilage and VSMC, was found to be one of the top expressed genes in the trabecular meshwork. The creation of an Mgp-lacZ Knock-In mouse and the use of mouse genetics revealed that in the eye, Mgp's abundant expression is localized and restricted to glaucoma-associated tissues from the anterior and posterior segments. In particular, it is specifically expressed in the regions of the trabecular meshwork and of the peripapillary sclera that surrounds the optic nerve. Because stiffness in these tissues would significantly alter outflow facility and biomechanical scleral stress in the optic nerve head (ONH), we propose MGP as a strong candidate for the regulation of stiffness in glaucoma. MGP further illustrates the presence of a common function affecting key glaucomatous parameters in the front and back of the eye, and thus offers the possibility for a sole therapeutic target for the disease.

Myopia Control: A Review

Slowing the progression of myopia has become a considerable concern for parents of myopic children. At the same time, clinical science is rapidly advancing the knowledge about methods to slow myopia progression. This article reviews the peer-reviewed literature regarding several modalities attempting to control myopia progression. Several strategies have been shown to be ineffective for myopia control, including undercorrection of myopic refractive error, alignment fit gas-permeable contact lenses, outdoor time, and bifocal of multifocal spectacles. However, a recent randomized clinical trial fitted progressing myopic children with executive bifocals for 3 years and found a 39% slowing of myopia progression for bifocal-only spectacles and 50% treatment effect for bifocal spectacles with base-in prism, although there was not a significant difference in progression between the bifocal-only and bifocal plus prism groups. Interestingly, outdoor time has shown to be effective for reducing the onset of myopia but not for slowing the progression of myopic refractive error. More effective methods of myopia control include orthokeratology, soft bifocal contact lenses, and antimuscarinic agents. Orthokeratology and soft bifocal contact lenses are both thought to provide myopic blur to the retina, which acts as a putative cue to slow myopic eye growth. Each of these myopia control methods provides, on average, slightly less than 50% slowing of myopia progression. All studies have shown clinically meaningful slowing of myopia progression, including several randomized clinical trials. The most investigated antimuscarinic agents include pirenzepine and atropine. Pirenzepine slows myopia progression by approximately 40%, but it is not commercially available in the United States. Atropine provides the best myopia control, but the cycloplegic and mydriatic side effects render it a rarely prescribed myopia control agent in the United States. However, low-concentration atropine has been shown to provide effective myopia control with far fewer side effects than 1.0% atropine. Finally, two agents, low-concentration atropine and outdoor time have been shown to reduce the likelihood of myopia onset. Over the past few years, much has been learned about how to slow the progression of nearsightedness in children, but we still have a lot to learn.

Relationship between visual field progression and baseline refraction in primary open-angle glaucoma

PURPOSE

To analyze the relationship between visual field (VF) progression and baseline refraction in Japanese patients with primary open-angle glaucoma (POAG) including normal-tension glaucoma.

PATIENTS AND METHODS

In this retrospective study, the subjects were patients with POAG who had undergone VF tests at least ten times with a Humphrey Field Analyzer (Swedish interactive thresholding algorithm standard, Central 30-2 program). VF progression was defined as a significantly negative value of mean deviation (MD) slope at the final VF test. Multivariate logistic regression models were applied to detect an association between MD slope deterioration and baseline refraction.

RESULTS

A total of 156 eyes of 156 patients were included in this analysis. Significant deterioration of MD slope was observed in 70 eyes of 70 patients (44.9%), whereas no significant deterioration was evident in 86 eyes of 86 patients (55.1%). The eyes with VF progression had significantly higher baseline refraction compared to those without apparent VF progression (-1.9±3.8 diopter [D] vs -3.5±3.4 D, P=0.0048) (mean ± standard deviation). When subject eyes were classified into four groups by the level of baseline refraction applying spherical equivalent (SE): no myopia (SE > -1D), mild myopia (-1D ≥ SE > -3D), moderate myopia (-3D ≥ SE > -6D), and severe myopia (-6D ≥ SE), the Cochran-Armitage trend analysis showed a decreasing trend in the proportion of MD slope deterioration with increasing severity of myopia (P=0.0002). The multivariate analysis revealed that baseline refraction (P=0.0108, odds ratio [OR]: 1.13, 95% confidence interval [CI]: 1.03-1.25) and intraocular pressure reduction rate (P=0.0150, OR: 0.97, 95% CI: 0.94-0.99) had a significant association with MD slope deterioration.

CONCLUSION

In the current analysis of Japanese patients with POAG, baseline refraction was a factor significantly associated with MD slope deterioration as well as intraocular pressure reduction rate. When baseline refraction was classified into four groups, MD slope in myopia groups was less deteriorated as compared to those in the emmetropic/hyperopic group.

Impact of Age and Myopia on the Rate of Visual Field Progression in Glaucoma Patients

Myopia is rapidly increasing in young populations and patients with glaucoma associated with myopia are reported to be young aged in East Asia. These young patients have a longer life expectancy, which increases their risk of end-of-life visual disabilities. There is a need to understand the clinical course of myopic glaucoma patients, which may be important for the care of these myopic populations. In this study, we evaluated the relationship between the age at presentation and the rate of glaucoma progression in the visual field (VF) according to the presence of myopia. The study was conducted as a prospective observational study including 179 patients with open-angle glaucoma who had undergone at least 5 VF examinations with a follow-up of at least 5 years. The progression rate of the mean deviation (MD) and the pattern standard deviation (PSD) are expressed as change in decibels (dB) per year. The slopes of the MD and PSD were calculated by linear regression analyses. Factors related to the slope of VF MD changes were analyzed with correlation and regression analyses. The slope of the linear fit line plotted against age at presentation and the rate of change in the VF MD was -0.026 (P < 0.001) in the myopic group and -0.008 (P = 0.167) in the nonmyopic group; the relationship was more prominent in the myopic group than the nonmyopic group. In the myopic group, age (β = -0.417; 95% confidence intervals (CI), -0.651 to -0.200; P = 0.050) and baseline untreated intraocular pressure (β = -0.179; 95% CI, -0.331 to -0.028; P = 0.022) were significantly related to the rate of change in the MD, which was only the presence of disc hemorrhage (β = -0.335; 95% CI, -0.568 to -0.018; P = 0.022) in the nonmyopic group. Age at presentation was significantly related to the rate of change in the VF in glaucomatous eyes with myopia compared to eyes without myopia. Older age was significantly related to the rate of change in the VF only in myopic glaucomatous eyes.

Axial Myopia Is Associated with Visual Field Prognosis of Primary Open-Angle Glaucoma

Purpose

To identify whether myopia was associated with the visual field (VF) progression of primary open-angle glaucoma (POAG).

Methods

A total of 270 eyes of 270 POAG followed up for more than 3 years with ≥9 reliable VFs by Octopus perimetry were retrospectively reviewed. Myopia was divided into: mild myopia (-2.99 diopter [D], 0), moderate myopia (-5.99, 3.00 D), marked myopia (-9.00, -6.00 D) and non-myopia (0 D or more). An annual change in the mean defect (MD) slope >0.22 dB/y and 0.30 dB/y was defined as fast progression, respectively. Logistic regression was performed to determine prognostic factors for VF progression.

Results

For the cutoff threshold at 0.22 dB/y, logistic regression showed that vertical cup-to-disk ratio (VCDR; p = 0.004) and the extent of myopia (p = 0.002) were statistically significant. When logistic regression was repeated after excluding the extent of myopia, axial length (AL; p = 0.008, odds ratio [OR] = 0.796) reached significance, as did VCDR (p = 0.001). Compared to eyes with AL≤23 mm, the OR values were 0.334 (p = 0.059), 0.309 (p = 0.044), 0.266 (p = 0.019), 0.260 (p = 0.018), respectively, for 23 <AL≤24 mm, 24 <AL≤25 mm, 25 <AL ≤26 mm, and AL>26 mm. The significance of vertical cup-to-disk ratio of (p = 0.004) and the extent of myopia (p = 0.008) did not change for the cutoff threshold at 0.30dB/y.

Conclusions

VCDR and myopia were associated with VF prognosis of POAG. Axial myopia may be a protective factor against VF progression.

Literature review and meta-analysis of translaminar pressure difference in open-angle glaucoma

There is increasing evidence in the literature regarding translaminar pressure difference's (TPD) role in the pathophysiology of glaucoma. The optic nerve is exposed not only to intraocular pressure in the eye, but also to intracranial pressure (ICP), as it is surrounded by cerebrospinal fluid in the subarachnoid space. Although pilot studies have identified the potential importance of TPD in glaucoma, limited available data currently prevent a comprehensive description of the role that TPD may have in glaucomatous pathophysiology. In this review, we present all available qualified data from a systematic review of the literature of the role of TPD in open-angle glaucoma (OAG). PubMed (Medline), OVID Medline, ScienceDirect, SpringerLink, and all available library databases were reviewed and subsequent meta-analysis of pooled mean differences are presented where appropriate. Five papers including 396 patients met criteria for inclusion to the analysis. Importantly, we included all observational studies despite differences in ICP measurement methods, as there is no consensus regarding best-practice ICP measurements in glaucoma. Our results show that not only TPD is higher in glaucoma patients compared with healthy subjects, it is related to structural glaucomatous changes of the optic disc. Our analysis suggests further longitudinal prospective studies are needed to investigate the influence of TPD in OAG, with a goal of overcoming methodological weaknesses of previous studies.

A hierarchical cluster analysis of normal-tension glaucoma using spectral-domain optical coherence tomography parameters

PURPOSE

Normal-tension glaucoma (NTG) is a heterogenous disease, and there is still controversy about subclassifications of this disorder. On the basis of spectral-domain optical coherence tomography (SD-OCT), we subdivided NTG with hierarchical cluster analysis using optic nerve head (ONH) parameters and retinal nerve fiber layer (RNFL) thicknesses.

PATIENTS AND METHODS

A total of 200 eyes of 200 NTG patients between March 2011 and June 2012 underwent SD-OCT scans to measure ONH parameters and RNFL thicknesses. We classified NTG into homogenous subgroups based on these variables using a hierarchical cluster analysis, and compared clusters to evaluate diverse NTG characteristics.

RESULTS

Three clusters were found after hierarchical cluster analysis. Cluster 1 (62 eyes) had the thickest RNFL and widest rim area, and showed early glaucoma features. Cluster 2 (60 eyes) was characterized by the largest cup/disc ratio and cup volume, and showed advanced glaucomatous damage. Cluster 3 (78 eyes) had small disc areas in SD-OCT and were comprised of patients with significantly younger age, longer axial length, and greater myopia than the other 2 groups.

CONCLUSIONS

A hierarchical cluster analysis of SD-OCT scans divided NTG patients into 3 groups based upon ONH parameters and RNFL thicknesses. It is anticipated that the small disc area group comprised of younger and more myopic patients may show unique features unlike the other 2 groups.

Correlation between central corneal thickness and myopia in Taiwan

The aim of the study was to explore the correlation between central corneal thickness (CCT) and the degree of myopia in Taiwanese adults. A total of 528 individuals were enrolled to undergo myopic laser refractive surgery from January 2004 to December 2006. Preoperative CCT was measured using the Orbscan corneal topography system and refractive status was determined by cycloplegic spherical equivalent. The relationship between CCT and refractive error was investigated by interindividual and intraindividual analyses. Participants had a mean age of 34.8 ± 7.3 years, and 79.9% were female. The mean refractive error was -7.27 ± 2.96 diopters and the mean CCT measurement was 560 ± 35 μm. CCT revealed that there was no association with age. However, CCT was significantly (p = 0.012) less in females than in males. The CCT also showed no significant association with refractive error (p = 0.49). Among the 67 participants with myopic anisometropia, the mean difference between both eyes was 3.09 ± 1.06 diopters. There was no association between the intereye CCT difference and refractive error (p = 0.57). The results remained the same after adjusting for age and sex. In conclusion, there was no correlation between CCT and the degree of myopia among adults in Taiwan. These data might contribute to the ongoing discussion about the role of CCT in the higher incidence of development and progression of glaucoma in myopic individuals.

Myopia and diabetes mellitus as modificatory factors of glaucomatous optic neuropathy

Myopic deformation of the eye and metabolic alterations of the nerve tissue of patients with diabetes may modify glaucomatous optic neuropathy (GON). Blockage of axonal transport of neurotrophic factors (NTFs) is the event crucial to understanding the factors that affect GON. The primary, but not sole, blockage site is at the lamina cribrosa (LC). Other than this primary site of damage at the LC, 7 other factors may explain atypical nerve fiber layer (NFL) defects and the vulnerability of the nerve fibers in eyes with high myopia and glaucoma: a second point of blockage at the edge of the posterior scleral foramen; ectatic strain on the NFL; ectasia and distortion of the LC; association of a hypoplastic optic disc; thin and weak collagen fibers; peripapillary chorioretinal atrophy; and myopic neuropathy. Among diabetic patients, diabetic neuropathy in the retinal NFL is present initially, and increased resistance to aqueous outflow leads to ocular hypertension. Superimposition of GON on diabetic neuropathy and ocular hypertension in patients with diabetes may enhance their susceptibility to nerve damage. Results of a meta-analysis study suggested a positive association between diabetes mellitus and glaucoma whereas other reports suggested that leakage of vascular endothelial growth factor, a survival mechanism of ischemic neural tissue, and enhanced stiffness of the LC as a result of diabetic glycation may protect neurons from apoptosis. Thus, modification of GON as a result of diabetes remains controversial.

Association between ganglion cell complex and axial length

PURPOSE

We evaluated the association between each layer of macular ganglion cell complex (mGCC) and axial length measured with spectral-domain optical coherence tomography (OCT).

METHODS

One hundred and one eyes of 101 healthy younger women were assessed in this prospective study. In one eye, mGCC was measured two times with 3D-OCT 2000 (Topcon). The associations between mGCC and axial length were analyzed using single regression analysis. To support the data of this study, repeatability also was assessed by intraclass correlation coefficient (ICC), coefficient of variance (CoV), and test-retest standard deviation (TRTSD).

RESULTS

In each layer of the mGCC, ICC ranged from 0.980 to 0.997; CoV ranged from 0.8 to 2.4 %; TRTSD ranged from 0.8 to 3.0 μm. For every 1 mm of greater axial length, total macular retinal nerve fiber layer (mRNFL) thickness increased by 1.1 μm (p < 0.01), and total macular ganglion cell layer and inner plexiform layer (mGCL+) and mGCC thickness decreased by 2.5 μm (p < 0.001) and 1.4 μm (p = 0.018), respectively.

CONCLUSIONS

In healthy younger participants, mGCC measurement using 3D OCT-2000 showed good repeatability. As axial length increased, total mGCC decreased, whereas total mRNFL and mGCL+ showed an inverse correlation.

Risk factors for progression of normal-tension glaucoma under β-blocker monotherapy

PURPOSE

To prospectively study prognostic factors for normal-tension glaucoma (NTG) under treatment with topical β-blocker.

METHODS

One hundred and forty-six eyes of 146 patients with NTG with a mean untreated intraocular pressure (IOP) of 14 mmHg, mild to moderate visual field damage and mean spherical equivalent refraction of -3.5 (-8.0 to +2.0) dioptre were randomized to topical nipradilol or timolol and followed for 3 years. The Humphrey full threshold 30-2 visual field test was performed every 6 months, and optic disc photographs were obtained every 12 months. Progression was defined as visual field progression, optic disc and/or peripapillary nerve fibre layer change, and factors relating to progression were evaluated using Cox proportional hazards models.

RESULTS

IOP decreased by 1.0 mmHg over the 3-year period, during which 35% showed progression according to the aforementioned criteria. Optic disc haemorrhage (hazard ratio [HR] 4.00, p < 0.001) and less extent of myopia (per dioptre, HR 1.15, p = 0.013) were significant risk factors. When progression was defined by visual field progression only, less extent of myopia was again a significant risk factor (HR 1.17, p = 0.038).

CONCLUSION

Beside optic disc haemorrhage, less extent of myopia was a risk factor for progression in the current NTG population where most patients were mildly myopic and IOP during follow-up averaged 13.2 mmHg under topical β-blocker.

The evidence base to select a method for assessing glaucomatous visual field progression

A large number of methods have been developed for assessing glaucomatous visual field progression, but their properties have not yet been systematically evaluated. In this systematic literature review, we summarize the evidence base for selecting a method by providing answers to ten relevant questions on the variety, validity and reproducibility of methods. In total, we found 301 different methods in 412 articles. The majority of studies (54%) used the Humphrey Field Analyzer. No data have been published about the reproducibility of methods. Although there is no gold standard to assess glaucomatous visual field progression, we found evidence on validity for 48 different methods. Some methods were less capable of distinguishing between progressive and nonprogressive patients. Choosing among twelve methods is supported by some evidence of their validity. These methods still differ in sensitivity, specificity and predictive values of test results within studies comparing several methods. In conclusion, the current evidence base is not perfect. A selection should be made from a limited number of methods, according to the clinical purpose of progression assessment. Methods that quantify the rate of visual field progression seem to be the most appropriate for guiding subsequent medical actions in individual patients. Future studies should investigate whether using one method to monitor patients is superior to another method in preventing loss of quality of life.

Evaluation of the choroidal thickness using high-penetration optical coherence tomography with long wavelength in highly myopic normal-tension glaucoma

PURPOSE

To evaluate the choroidal thickness by high-penetration optical coherence tomography (OCT) using long wavelength in highly myopic normal-tension glaucoma (NTG).

DESIGN

Cross-sectional retrospective study.

METHODS

SETTINGS

Institutional.

PARTICIPANTS

Twelve eyes from 8 patients under 45 years old, diagnosed as NTG without any other ocular diseases, spherical equivalent refractive error between -6 and -12 diopters, and axial length greater than 26.5 mm; and 12 eyes of matched healthy volunteers.

INTERVENTION

Choroid was imaged with prototype high-penetration OCT and its thickness was measured.

MAIN OUTCOME MEASURES

Choroidal thickness at the fovea and 5 locations: 2 mm superior, temporal, and inferior to the center of the optic nerve head, and 2 mm superior (superotemporal) and 2 mm inferior (inferotemporal) to the temporal location.

RESULTS

Overall, the choroidal thickness in the NTG group was approximately 50% that in controls. Mean choroidal thickness in the NTG group was significantly thinner in the control group at the fovea (166 vs 276 μm, P < .001), superior (172 vs 241 μm, P < 0.05), superotemporal (161 vs 244 μm, P < .01), temporal (110 vs 161 μm, P < .01), and inferotemporal (115 vs 159 μm, P < .05) to the optic nerve head. Stepwise analysis disclosed that the foveal choroidal thickness is the most influential factor on the occurrence of NTG (P < .0001, R(2) = 0.4).

CONCLUSIONS

Choroidal thickness in highly myopic NTG is significantly thinner than in controls, at least in some specific locations. Choroidal thinning is somehow related with highly myopic NTG and may be a useful diagnostic parameter for myopic NTG.

Clinical characteristics and outcomes of cataract surgery in highly myopic Koreans

Purpose

To evaluate the clinical characteristics and outcomes of cataract surgery in highly myopic Korean subjects.

Methods

We retrospectively reviewed the medical records of 694 eyes of 694 patients who underwent cataract surgery. The case group included 347 eyes of 347 patients whose axial lengths (AXL) were ≥26.00 mm, and the control group included 347 eyes of 347 patients with AXL between 22.00 and 25.99 mm. Cataract density was determined preoperatively using the Pentacam Scheimpflug imaging system. We compared age at operation, cataract type, coexisting disease, visual prognosis, and complications.

Results

The mean age at the time of the operation was 59.60 ± 12.28 years in the case group and 67.47 ± 11.36 years in the control group. The case group had a larger proportion of nuclear cataracts and posterior subcapsular cataracts (PSC), 40.63% and 26.22%, respectively, versus 25.07% and 11.82%, respectively, in the control group. Postoperative corrected visual acuity showed a negative correlation with AXL (R² = 0.172), and severe funduscopic findings were related to poor visual prognosis (p = 0.05). The incidence of retinal detachment in the case group after cataract surgery was 1.72%, compared with 0.28% in the control group.

Conclusions

Highly myopic eyes tend to develop cataracts earlier than normal eyes and to have a higher prevalence of coexisting disease and complications, such as retinal detachment. Nuclear cataracts and PSC were more common in the highly myopic group. Poor visual prognosis was associated with longer axial length and retinal myopic degeneration.