Peripapillary Atrophy in High Myopia

Peripapillary atrophy in patients with birdshot chorioretinitis

AIMS

This study aims to analyse peripapillary atrophy (PPA), its frequency, extent and relation with measures of visual function in patients with birdshot chorioretinitis (BSCR).

METHODS

Patients of the single-centre prospective COhort of patients with BIRDshot chorioretinitis (ClinicalTrials.gov Identifier: NCT05153057) were included. The areas of the optic nerve head (ONH) and PPA were measured on red-green and autofluorescence fundus images acquired by ultrawidefield retinal photography. The main outcome measure was the frequency of PPA. Correlations between the PPA/ONH ratio and disease duration, age, best corrected visual acuity (BCVA) and visual field results (mean deviation (MD) and the pattern SD (PSD)-Humphrey perimeter 30-2) were evaluated using the Spearman coefficient.

RESULTS

A total of 752 eyes from 384 patients (mean age 62.4±12.1 years) were included. The median disease duration was 13.0 (7.0-19.0) years. PPA was observed in 717 (95.4%) eyes. The mean PPA/ONH ratio was 2.9±2.2 on red-green images, 3.1±2.2 on autofluorescence, and these measures were highly correlated (R=0.95, p<0.0001). The ratio of PPA/ONH increased with the duration of the disease (R=0.57, p<0.0001) from 1.6±0.6 in the 0-5 years group to 5.2±2.9 after 25 years and with age (R=0.51, p<0.0001). PPA was also associated with a worse BCVA (R=-0.42, p<0.0001) and worse visual field results: MD (R=-0.41, p<0.0001), PSD (R=0.42, p<0.0001). A strong intereye symmetry of the PPA/ONH ratio was observed (R=0.91, p<0.0001), which was greater than that of BCVA (R=0.58, p<0.0001), MD (R=0.76, p<0.0001) or PSD (R=0.70, p<0.0001).

CONCLUSIONS

Almost all patients with BSCR exhibit PPA and its extent increases over time. PPA is associated with poorer vision.

Automated measurement and correlation analysis of fundus tessellation and optic disc characteristics in myopia

This study aims to quantify fundus tessellated (FT) density and optic disc (OD) morphology using deep learning (DL) techniques and to investigate the correlations between these fundus characteristics and refractive function in young patients with myopia. We constructed two DL-based segmentation models to delineate the FT, OD, peripapillary atrophy (PPA), and macula at a pixel-level resolution. The study sought to identify differences in fundus characteristics between eyes categorized as having high myopia versus mild or moderate myopia. Furthermore, the correlation between fundus measurements and various ocular parameters was statistically analyzed. Correlation analysis indicated that the spherical equivalent and axial length were significantly associated with all fundus measurements (p < 0.001). Additionally, corneal curvature (K1, K2), lens thickness, and foveal thickness exhibited significant correlations with some of the fundus measurements at a 0.01 significance level. Using DL algorithms, it is feasible to automatically quantify FT and OD characteristics in young myopic patients. The study findings suggest that both FT and OD characteristics are highly correlated with the severity of myopia, particularly as it progresses from mild or moderate to high levels. Moreover, a significant relationship exists between most of these fundus characteristics and a spectrum of refractive function parameters.

Retinal nerve fiber layer thickness and radial peripapillary capillaries density in myopic adults with optical coherence tomography angiography

PURPOSE

To evaluate retinal nerve fiber layer thickness (RNFLT) and radial peripapillary capillaries (RPC) density in adults with different degrees of myopia using optical coherence tomography angiography (OCTA) and explore their relationship with ocular factors, such as axial length (AL) and disc area.

METHODS

A total of 188 subjects were included in this cross-sectional study. The eyes were divided into four groups according to AL. OCTA was used for the assessment of RNFLT, RPC density, and other optic disc measurements, such as disc area. One-way analysis of variance was performed to compare differences between four groups, and P value < 0.01 was considered significant.

RESULTS

The RNFLT was significantly thinner in high myopia (HM) group at inferior nasal (IN) quadrant (P = 0.004) than low myopia (LM) group, but thicker at temporal inferior (TI) quadrant (P = 0.006). The RPC density of nasal superior (NS) quadrant, nasal inferior (NI) quadrant, and inferior nasal (IN) quadrant significantly decreased as AL increasing. By simple linear regression analysis, the inside disc RPC (iRPC) density tended to be correlated significantly with AL (0.3997%/mm, P < 0.0001). Peripapillary RPC (pRPC) density was in significant correlation with AL (-0.2791%/mm, P = 0.0045), and peripapillary RNFLT (pRNFLT) was in significant correlation with disc area (0.2774%/mm2, P = 0.0001).

CONCLUSION

RNFLT and RPC density were closely associated with AL and disc area. They might be new indexes in assessing and detecting myopia development via OCTA.

Characteristics of the Peripapillary Structure and Vasculature in Patients With Myopic Anisometropia

Purpose

To evaluate the interocular differences of the peripapillary structural and vascular parameters and that of association with axial length (AL) in participants with myopic anisometropia using swept-source optical coherence tomography.

Methods

This prospective cross-sectional study included 90 eyes of 45 participants. Each participant's eyes were divided into the more and less myopic eye respectively according to spherical equivalent. The β- and γ-parapapillary atrophy (PPA) areas, Bruch's membrane opening distance, border length, and border tissue angle were measured manually. Peripapillary choroidal vascularity index and choroidal thickness (CT) values in superior, nasal, inferior, and temporal were calculated using a custom-built algorithm based on MATLAB.

Results

The interocular difference in AL and spherical equivalent was 0.62 ± 0.26 mm and -1.50 (-2.13, -1.25) diopters (D), respectively. The interocular difference in spherical equivalent was highly correlated with that of the AL. The β- and γ-PPA areas were significantly greater in more myopic eyes. The mean and inferior peripapillary choroidal vascularity index and all regions of peripapillary CT were significantly lower in the more myopic eyes. The interocular difference in AL was significantly positively correlated with the interocular differences in γ-PPA area and border length and negatively correlated with the interocular differences in temporal choroidal vascularity index and mean, inferior, and temporal peripapillary CT. There was an independent correlation between the interocular differences in AL and the interocular differences in γ-PPA area, inferior, and temporal peripapillary CT.

Conclusions

Significant differences between both groups were detected in most peripapillary parameters, especially in peripapillary CT. The γ-PPA area, border length, and peripapillary CT were significantly correlated with the elongation of AL.

Translational Relevance

The current study characterized and analyzed the peripapillary parameters in myopic anisometropia, which helped to monitor myopic progression.

Distribution of the Retinal Microcirculation Based on the Morphology of Peripapillary Atrophy in High Myopia

INTRODUCTION

The objective of this study was to evaluate the retinal microvasculature of the optic nerve head and macula in high myopia (HM), investigate the association between the vascular parameters and peripapillary atrophy (PPA) deformation, and assess and identify the PPA morphology changes during the development of HM.

METHODS

One hundred sixty-seven right eyes from 167 HM patients were enrolled in this cross-sectional study. Using the optical coherence tomography angiography (OCTA) and fundus camera, we evaluated the following parameters: radian and type of PPA, intrapapillary vascular density (IVD), peripapillary vascular density (PVD), macular vascular density (MVD), and foveal avascular zone (FAZ). Based on the PPA radian, subjects were divided into four groups: the non-PPA, temporal PPA, advanced PPA, and annular PPA. At the same time, the above parameters were compared between the groups using analysis of variance (ANOVA) and least significant difference test.

RESULTS

Total enrolled patients were divided into the non-PPA group (22 eyes), temporal-PPA group (70 eyes), advanced-PPA group (60 eyes), and annular-PPA group (15 eyes). The results showed that the PVD in the annular-PPA group was smaller than that in the non-PPA group, especially in the superonasal, nasosuperior, nasoinferior, inferotemporal, temporoinferior, and superotemporal directions (F = 4.059, 5.014, 2.830, 4.798, 5.892, 3.439; p < 0.05). Notably, the PVD showcased the highest value in temporal, followed by that in superior and inferior, and the lowest in the nasal. Concerning the fovea deep macular vascular density, FAZ area, and subfoveal choroidal thickness in the annular-PPA group, they were less than those of the rest of the groups (p < 0.05).

CONCLUSION

The retinal microvasculature differed significantly in HM according to the PPA morphology. In addition to PVD and SFCT, the PPA can also affect FAZ. Finally, we speculated that PVD demonstrated better predictability of myopic progression than MVD.

Characteristics of the optic disc in young people with high myopia

PURPOSE

This study aimed to investigate the characteristics of the optic disc in adolescents and young adults with high myopia by applying optical coherence tomography angiography.

METHODS

A total of 112 patients with high myopia (spherical equivalent refraction (SER) ≤ -6.00 D) aged 12 to 30 years old were enrolled in this cross-sectional study. Parapapillary atrophy (PPA) and ovality index from scanning laser ophthalmoscopy images and the degree of optic disc tilt from the optic nerve head (ONH) OCT B-scans were analysed using ImageJ and MATLAB software. Peripapillary retinal nerve fibre layer thickness (pRNFLT) and radial peripapillary capillary vessel density (RPC VD) around the optic disc were obtained from the images of the optic disc angiography scan.

RESULTS

In young high myopia patients, the PPA area was positively correlated with age, axial length (AL) and pRNFLT (all p < 0.05) and negatively correlated with SER (r = -0.222, p = 0.020). The degree of the optic disc tilt was associated with increasing AL and pRNFLT (all p < 0.05). The disc area was positively correlated with AL, pRNFLT, and RPC VD (all p < 0.05). In the multivariate regression analysis, PPA area was independently associated with the degree of optic disc tilt and disc area. The degree of optic disc tilt was affected by AL and PPA area while the change of disc area was influenced by PPA area and pRNFLT (all p < 0.05).

CONCLUSION

In young patients with high myopia, PPA area, the degree of optic disc tilt and disc area increased with AL and pRNFLT, while decreased with SER. The association between these factors was slightly different in the adolescent and young adult groups. The degree of the optic disc tilt was more associated with AL and SER in the adolescent group while disc area showed more correlated with AL and SER in the young adult group.

The prevalance of congenital optic disc anomalies in Turkey: a hospital-based study

PURPOSE

The aim of this study was to investigate the prevalence of congenital optic disc anomalies in Turkey.

METHODS

The 11,123 eyes of 5570 patients were screened for optic disc anomalies. All patients were underwent a complete ophthalmic examination including best corrected visual acuity, refraction, spherical equivalent, slit lamp biomicroscopy, intraocular pressure measurements, dilated stereoscopic fundus examination. Data analyses were performed by using SPSS for Windows, version 22.0 (SPSS Inc., Chicago, IL, United States).

RESULTS

11,123 eyes of 5570 participants were screened. Of the 5570 participants who underwent optic disc examination, 246 eyes of 174 patients (3.12%, 95% CIs 2.66-3.58%) had optic disc anormalies. 92 (52.9%) were female, 82 (47.1%) were male and the mean of age was 44.25 ± 15.67 years. 72 (41.4%) patients were bilateral, 102 (58.6%) patients were unilateral involvement. The tilted disc was the most common anomaly and was found at least one eye in 46 patients (75 eyes) and 0.83% of all screened patients. Peripapillary myelinated nerve fibers was the second common anomaly and was found at least one eye in 31 subjects (35 eyes) and 0.56% of all screened subjects. Peripapillary atrophy was the third common anomaly, and was found in at least one eye in 24 patients (37 eyes) and 0.43% of all screened subjects.

CONCLUSION

To our knowledge, this is the first study that the prevalences of all congenital optic disc anomalies from Turkey. The prevalence of congenital optic disc anomalies is higher than in other countries.

The association of myopia progression with the morphological changes of optic disc and β-peripapillary atrophy in primary school students

PURPOSE

To study the association of myopia progression with the morphological changes of optic disc and β-peripapillary atrophy (β-PPA) in 8-11 years old primary school students.

METHODS

This study was a prospective, school-based investigation. This study included 610 children (1008 eyes) who were continuously observed and had data available from 2016 to 2017 in the Sanhe Cohort Study of the Risk Factors for Myopia (SCSRFM). The children underwent a comprehensive eye examination including measurement of visual acuity, autorefractometry, and posterior segment of the eye. β-PPA regions and optic disc ovality index were identified and measured on the fundus photographs.

RESULTS

The prevalence of myopia was 72.62% (732/1008) in 2016. In myopic children, the prevalence of the vertical β-PPA, the horizontal β-PPA, and the oval optic disc were 75.68% (554/732), 75.96% (556/732) and, 11.61% (85/732) respectively. From 2016 to 2017, with the progression of vertical β-PPA, horizontal β-PPA, area of β-PPA, and optic disc ovality index, the myopic diopter and the axial length (AL) were increased. The progression of horizontal β-PPA was significantly correlated with the progression of myopic diopter and AL (all p < 0.05). The analysis on the distribution of progression rate of parameters in different groups found that the progression rate of horizontal β-PPA, area of β-PPA, and optic disc ovality index increased with the increase of the progression of diopter and AL. The progression of horizontal β-PPA, area of β-PPA, optic disc ovality index, and diopter in girls were greater than that in boys, and the progression of optic disc ovality index and diopter had a statistical significance (all p < 0.05).

CONCLUSIONS

The 1-year follow-up study of the third-grade primary school students showed that with the progression of myopia and the growth of AL, β-PPA and optic disc ovality index also changed. There was a positive correlation between the change of β-PPA and optic disc ovality index and the progression of myopia diopter and AL.

Design and Pilot data of the high myopia registration study: Shanghai Child and Adolescent Large-scale Eye Study (SCALE-HM)

PURPOSE

To describe the methodology and pilot data of the Shanghai Child and Adolescent Large-scale Eye Study (SCALE-HM).

METHODS

This is a population-based, prospective, examiner-masked study with annual follow-up. Patients are 4- to 18-year-olds with high myopia. The participants will fill out questionnaires and then undergo visual acuity, axial length (AL), intraocular pressure, ophthalmologist assessment, microperimetry, cycloplegic refraction, Pentacam, wavefront aberration, fundus, blood and saliva examinations. To describe the pilot data, intergroup differences were assessed with t-tests or analysis of variance and a logistic regression model was used to determine the independent factors associated with peripapillary atrophy (PPA).

RESULTS

Overall, 134 eyes of 79 participants met the pilot study recruitment criteria. The mean AL and spherical equivalent were 26.91 ± 1.07 mm and -9.40 ± 1.77 D, respectively. Peripapillary atrophy (PPA) (N = 112) and tessellated fundus (N = 67) were the most common fundus changes. The mean AL was significantly longer in PPA (27.08 ± 0.93 mm) than in non-PPA eyes (26.06 ± 1.31 mm; p < 0.001). Axial length (AL) (p = 0.041) was the only independent factor associated with PPA. Axial length (AL) was significantly longer in eyes with diffuse chorioretinal atrophy (N = 11; 28.02 ± 1.31 mm) than without myopic retinal lesions (N = 56; 26.48 ± 0.91 mm, p < 0.001) or with tessellated fundus (N = 67; 27.09 ± 0.97 mm, p = 0.012). The myopic degree was higher in eyes with diffuse chorioretinal atrophy than without myopic retinal lesions (-10.51 ± 2.76 D versus -9.06 ± 1.58 D, p = 0.039).

CONCLUSION

Peripapillary atrophy and tessellated fundus were common in children and adolescents with high myopia. Results from this prospective study will help to understand the mechanisms, development and prognosis of these changes and can guide early myopia screening.

Optical Coherence Tomography Can Be Used to Assess Glaucomatous Optic Nerve Damage in Most Eyes With High Myopia

PRECIS

It is generally assumed that optical coherence tomography (OCT) cannot be used to diagnose glaucomatous optic neuropathy (GON) in high myopes. However, this study presents evidence that there is sufficient information in OCT scans to allow for accurate diagnosis of GON in most eyes with high myopia.

PURPOSE

The purpose of this study was to test the hypothesis that glaucomatous damage can be accurately diagnosed in most high myopes via an assessment of the OCT results.

PATIENTS AND METHODS

One hundred eyes from 60 glaucoma patients or suspects, referred for OCT scans and evaluation, had corrected spherical refractive errors worse than -6 D and/or axial lengths ≥26.5 mm. An OCT specialist judged whether the eye had GON, based upon OCT circle scans of the disc and cube scans centered on the macula. A glaucoma specialist made the same judgement using all available information (eg, family history, repeat visits, intraocular pressure, 10-2 and 24-2 visual fields, OCT). A reference standard was created based upon the glaucoma specialist's classifications. In addition, the glaucoma specialist judged whether the eyes had peripapillary atrophy (PPA), epiretinal membrane (ERM), tilted disc (TD), and/or a paravascular inner retinal defect (PIRD).

RESULTS

The OCT specialist correctly identified 97 of the 100 eyes using the OCT information. In 63% of the cases, the inner circle scan alone was sufficient. For the rest, additional scans were requested. In addition, 81% of the total eyes had: PPA (79%), ERM (18%), PIRD (26%), and/or TD (48%).

CONCLUSIONS

For most eyes with high myopia, there is sufficient information in OCT scans to allow for accurate diagnosis of GON. However, the optimal use of the OCT will depend upon training to read OCT scans, which includes taking into consideration myopia related OCT artifacts and segmentation errors, as well as PPA, ERM, PIRD, and TD.

Choroidal and peripapillary changes in high myopic eyes with Stickler syndrome

Background

To compare different clinical and Spectral-Domain Optical Coherence Tomography (SD-OCT) features of high myopic eyes with Stickler syndrome (STL) with matched controls.

Methods

Patients with genetically confirmed STL with axial length ≥ 26 mm and controls matched for axial length were included. The following data were obtained from SD-OCT scans and fundus photography: choroidal and retinal thickness (respectively, CT and RT), peripapillary atrophy area (PAA), presence of posterior staphyloma (PS).

Results

Twenty-six eyes of 17 patients with STL and 25 eyes of 19 controls were evaluated. Compared with controls, patients with STL showed a greater CT subfoveally, at 1000 μm from the fovea at both nasal and temporal location, and at 2000 and 3000 μm from the fovea in nasal location (respectively, 188.7±72.8 vs 126.0±88.7 μm, 172.5±77.7 vs 119.3±80.6 μm, 190.1±71.9 vs 134.9±79.7 μm, 141.3±56.0 vs 98.1±68.5 μm, and 110.9±51.0 vs 67.6±50.7 μm, always P< 0.05). Furthermore, patients with STL showed a lower prevalence of PS (11.5% vs 68%, P< 0.001) and a lower PAA (2.2±2.1 vs 5.4±5.8 mm², P=0.03), compared with controls.

Conclusions

This study shows that high myopic patients with STL show a greater CT, a lower PAA and a lower prevalence of PS, compared with controls matched for axial length. These findings could be relevant for the development and progression of myopic maculopathy in patients with STL.

Posterior segment conditions associated with myopia and high myopia

Myopia, and especially high myopia, is associated with a number of posterior segment changes that are considered to be mostly a consequence of the increased axial elongation. This can result in mechanical strain, attendant vascular changes, stretching and thinning of tissues, and atrophy/deformation of tissues in later or more advanced stages. Such myopia-related changes are observed as changes and/or abnormalities in the vitreous, choroid, retina and peripheral retina, sclera and/or optic disc. Although many of these changes are benign, at times they may be associated with significant vision impairment that either requires active intervention or may suggest future progression of the disease. This review systematically addresses the posterior segment conditions seen in myopic eyes, describes the features associated with the condition and details management pathways.

Screening for Myopia-Related Retinal Changes Among Teenagers

BACKGROUND AND OBJECTIVE

To evaluate the relationship between spherical equivalent (SE) refractive error and myopia-related peripheral retinal changes (MPRCs) and to find the optimal cutoff for screening myopic teenagers.

PATIENTS AND METHODS

The study included 2,286 myopic subjects who had a dilated fundus examination between 1998 and 2011 and SE of -4.0 diopters (D) or higher in both eyes.

RESULTS

Ninety-five subjects (4.16%) had MPRCs. Two subjects (0.09%) had moderate-to-severe MPRCs. A significant correlation (P < .0001) between SE and MPRC was found. The highest sum of sensitivity (72.63%) and specificity (73.44%) was achieved when a SE of -6.25 D in the more myopic eye was utilized as the cutoff.

CONCLUSIONS

SE and MPRCs are highly associated. The optimal cutoff to detect MPRC in teenagers is -6.25 D. However, using a SE of -4.0 D as the cutoff may be the practical choice for screening due to the noninvasiveness nature and low cost of the examination. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e311-e319.].

Current applications of machine learning in the screening and diagnosis of glaucoma: a systematic review and Meta-analysis

AIM

To compare the effectiveness of two well described machine learning modalities, ocular coherence tomography (OCT) and fundal photography, in terms of diagnostic accuracy in the screening and diagnosis of glaucoma.

METHODS

A systematic search of Embase and PubMed databases was undertaken up to 1^st of February 2019. Articles were identified alongside their reference lists and relevant studies were aggregated. A Meta-analysis of diagnostic accuracy in terms of area under the receiver operating curve (AUROC) was performed. For the studies which did not report an AUROC, reported sensitivity and specificity values were combined to create a summary ROC curve which was included in the Meta-analysis.

RESULTS

A total of 23 studies were deemed suitable for inclusion in the Meta-analysis. This included 10 papers from the OCT cohort and 13 from the fundal photos cohort. Random effects Meta-analysis gave a pooled AUROC of 0.957 (95%CI=0.917 to 0.997) for fundal photos and 0.923 (95%CI=0.889 to 0.957) for the OCT cohort. The slightly higher accuracy of fundal photos methods is likely attributable to the much larger database of images used to train the models (59 788 vs 1743).

CONCLUSION

No demonstrable difference is shown between the diagnostic accuracy of the two modalities. The ease of access and lower cost associated with fundal photo acquisition make that the more appealing option in terms of screening on a global scale, however further studies need to be undertaken, owing largely to the poor study quality associated with the fundal photography cohort.

Association between retinal microvasculature and optic disc alterations in high myopia

Purpose

This study aimed to explore the characteristics of retinal perfusion and its associations with high myopia.

Methods

A total of 760 participants were included. Peripapillary radial peripapillary capillary perfusion, foveal avascular zone, and parafoveal perfusion were measured using optical coherence tomography angiography (OCTA). Tilted disc ratio and parapapillary atrophy were determined using swept-source optical coherence tomography.

Results

A total of 760 young healthy participants with myopic eyes were included in the analysis. The mean axial length and titled disc ratio were 26.43 ± 1.14 and 0.76 ± 0.08 mm in the high-myopia group and 24.79 ± 0.75 and 0.80 ± 0.09 mm in the control group, respectively. The high-myopia group exhibited significantly larger parapapillary atrophy, lower tilted disc ratio, lower radial peripapillary capillary vessel density, larger area of foveal avascular zone, and lower deep parafoveal vessel density. In the multivariate analysis, titled disc ratio significantly correlated with radial peripapillary capillary vessel density (P = 0.0134), larger foveal avascular zone (P = 0.0062), and lower deep parafoveal vessel density (P < 0.0001).

Conclusions

Reduced radial peripapillary capillary and deep parafoveal vessel density and enlarged area of foveal avascular zone were observed in high myopia. Tilted disc ratio correlated with retinal perfusion.

Clinical features of superficial and deep peripapillary microvascular density in healthy myopic eyes

PURPOSE

To evaluate the clinical features of peripapillary microvasculature in myopic eyes and investigate the association between the superficial and deep peripapillary microvascular density and the myopic optic disc characteristics.

MATERIALS AND METHODS

This cross-sectional study included one hundred and fifty healthy myopic eyes with β-peripapillary atrophy (β-PPA). Ovality index, degree of optic disc rotation, and the area of β-PPA were measured. Superficial and deep peripapillary microvascular density was measured using optical coherence tomography angiography. Logistic regression analysis was performed to look for the factors associated with peripapillary microvascular reduction.

RESULTS

The mean superficial peripapillary microvascular density was 62.14 ± 5.47%; 33 (22.0%) participants were found to have decreased microvascular density. Increased axial length (p < 0.001) and decreased average peripapillary retinal nerve fiber layer thickness (p = 0.027) were associated with the superficial peripapillary microvascular reduction. The mean deep peripapillary microvascular density was 73.76 ± 4.02%; 26 (17.33%) participants were found to have decreased microvascular density. Larger ovality index (p = 0.028) and more inferiorly rotated optic disc (p = 0.021) were associated with the deep peripapillary microvascular reduction.

CONCLUSIONS

Axial elongation was significantly associated with microvascular reduction in the superficial peripapillary retina, whereas it was not associated with deep peripapillary microvascular reduction. The deep peripapillary microvascular density was independently associated with myopic optic disc characteristics such as ovality index and optic disc rotation.