Causes of Low Vision and Blindness in Adult LatinosThe Los Angeles Latino Eye Study

Performance of artificial intelligence for the detection of pathological myopia from colour fundus images: a systematic review and meta-analysis

BACKGROUND

Pathological myopia (PM) is a major cause of worldwide blindness and represents a serious threat to eye health globally. Artificial intelligence (AI)-based methods are gaining traction in ophthalmology as highly sensitive and specific tools for screening and diagnosis of many eye diseases. However, there is currently a lack of high-quality evidence for their use in the diagnosis of PM.

METHODS

A systematic review and meta-analysis of studies evaluating the diagnostic performance of AI-based tools in PM was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Five electronic databases were searched, results were assessed against the inclusion criteria and a quality assessment was conducted for included studies. Model sensitivity and specificity were pooled using the DerSimonian and Laird (random-effects) model. Subgroup analysis and meta-regression were performed.

RESULTS

Of 1021 citations identified, 17 studies were included in the systematic review and 11 studies, evaluating 165,787 eyes, were included in the meta-analysis. The area under the summary receiver operator curve (SROC) was 0.9905. The pooled sensitivity was 95.9% [95.5%-96.2%], and the overall pooled specificity was 96.5% [96.3%-96.6%]. The pooled diagnostic odds ratio (DOR) for detection of PM was 841.26 [418.37-1691.61].

CONCLUSIONS

This systematic review and meta-analysis provides robust early evidence that AI-based, particularly deep-learning based, diagnostic tools are a highly specific and sensitive modality for the detection of PM. There is potential for such tools to be incorporated into ophthalmic public health screening programmes, particularly in resource-poor areas with a substantial prevalence of high myopia.

MACULAR CHORIORETINAL ATROPHY AND VISUAL OUTCOMES IN RANIBIZUMAB- OR AFLIBERCEPT-TREATED MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To investigate the predictors of macular chorioretinal atrophy, consisting of patchy atrophy (PA) at the macula and choroidal neovascularization (CNV)-related macular atrophy (CNV-MA), during treatment with ranibizumab or aflibercept for myopic CNV (mCNV) and its impact on visual outcomes.

METHODS

This retrospective study included 82 eyes with treatment-naïve mCNV who were treated with pro re nata injections of ranibizumab or aflibercept.

RESULTS

Nine eyes (11.0%) presented with macular PA at baseline (PA group), and 73 eyes (89.0%) did not (non-PA group). VA improved during the first year in the non-PA group; a similar trend was noted in the PA group until 3 months after initial treatment. This improvement was maintained until 24 months ( P < 0.001) in the non-PA group, but not in the PA group. In the PA group, macular chorioretinal atrophy progressed faster ( P < 0.0001), and CNV-MA was more frequent during the 2 years of treatments ( P = 0.04). Even non-PA group eyes sometimes developed CNV-MA (42% at Month 24) if they had a larger CNV and thinner subfoveal choroidal thickness at baseline, resulting in poorer visual prognosis ( P < 0.01).

CONCLUSION

Macular PA at baseline was a risk factor for CNV-MA development and was associated with poor visual outcomes.

Association Between Choroidal Thickness and Myopic Maculopathy in a Japanese Population: The Hisayama Study

Purpose

To examine the association between choroidal thickness and myopic maculopathy in a general Japanese population.

Design

Population-based cross-sectional study.

Participants

A total of 2841 residents of a Japanese community aged ≥ 40 years, who consented to participate and had available data of choroidal thickness and fundus photographs, were enrolled in this study.

Methods

The choroidal thickness was measured by swept-source OCT. Participants were divided into quartiles of choroidal thickness. Myopic maculopathy was defined according to the classification system of the Meta-analysis of Pathologic Myopia Study Group. Main outcome measures were odds ratios (ORs) of choroidal thickness for prevalent myopic maculopathy. The ORs and 95% confidence intervals (CIs) were estimated using a logistic regression model.

Main Outcome Measures

Prevalent myopic maculopathy.

Results

Eighty-one participants had myopic maculopathy (45 diffuse chorioretinal atrophy, 31 patchy chorioretinal atrophy, and 5 macular atrophy). Individuals in the lowest quartile of choroidal thickness had a significantly greater OR for the presence of myopic maculopathy than those in the highest quartile of choroidal thickness (OR: 4.78 [95% CI: 1.78-16.72]) after adjusting for confounders, including axial length. The sensitivity analysis among the 1176 myopic individuals with axial length of ≥ 24.0 mm also showed that thinner choroidal thickness was significantly associated with prevalent myopic maculopathy.

Conclusions

The present study demonstrated the significant inverse association between choroidal thickness and the likelihood of myopic maculopathy, suggesting that the measurement of choroidal thickness in addition to axial length would be useful for assessing the risk of myopic maculopathy and elucidating its pathogenesis.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Inhaled Corticosteroid Exposure and Risk of Cataract in Patients with Asthma and COPD: A Systematic Review and Meta-Analysis

Purpose

Both systemic and inhaled corticosteroids may increase the risk of cataract in patients with both chronic obstructive pulmonary disease (COPD) and asthma. Our aim was to assess the degree of association between cataract and corticosteroid exposure in patients with asthma and COPD.

Methods

A systematic literature review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The odds ratio estimates were extracted from each article. A random effects model was applied for estimate pooling in separate meta-analyses according to study design. Meta-regression was performed to assess the dose-response relationship between corticosteroid exposure and the risk of cataract development.

Results

A total of 19 studies met the criteria for inclusion in this review, of which 12 studies provided effect estimates for pooled analyses. All but one of the included observational studies reported a significant association between use of corticosteroids and cataract development in cohorts of asthma and/or COPD patients. Pooled analyses revealed on average a doubled risk of cataract in corticosteroid-exposed asthma and COPD patients. Studies have shown that daily high-dose inhaled corticosteroid (ICS) ≥ 1000 μg is associated with a significant risk of developing cataract and by that predispose to subsequent cataract surgery, although one study showed that systemic corticosteroids increase cataract risk more than ICS.

Conclusion

ICS treatment in asthma and COPD patients is a risk factor for cataract development. Our results emphasize a previously underestimated potential long-term risk of treatment with ICS and underline the importance of targeting ICS treatment, and not least dosing, to improve the risk-benefit ratio of maintenance treatment in both asthma and COPD.

The Impact of Cost-Containment Schemes on Outpatient Services for Schoolchildren with Refractive Errors in Taiwan—A Population-Based Study

Objectives: Extant research on cost-sharing finds no impact on health care utilization when the amount is insubstantial. This research investigates the effects on nonacute outpatient services for schoolchildren with refractive errors in Taiwan and discusses the potential harm caused by cost sharing and relevant cost containment policies. Methods: Longitudinal claims data from the National Health Insurance database are employed. District demographic information is also used for aggregate-level analyses. Interventional modeling is conducted on pooled individual-level data with a Poisson model and negative binomial models. Generalized least square modeling is performed on aggregate district-level data to elucidate the impacts of cost sharing and the reimbursement rate with controls for patient and institutional characteristics, district socioeconomic factors, and competitiveness among institutions. Results: The findings of this study show that cost sharing does not significantly affect children’s utilization of outpatient services in the patient-level analyses. However, it significantly decreases the service volume based on the results of district aggregate analyses. There are potentially marginal patients in society, and they are more likely to be girls in poorer families, whose chances of seeking medical care significantly decrease when cost sharing increases. Conclusions: The gap in health inequity can be widened when stringent cost-containment policies are implemented. The offset effect caused by delayed care may also result in higher health care expenditures later. Cost sharing for children should be separately and prudently designed to better protect them from deprivations caused by changes in health policies.

Etiología de baja visión y ceguera en siete centros de referencia en Colombia entre los años 2012 a 2017

Introducción: la baja visión y la ceguera tienen alta prevalencia mundial, siendo categorías de discapacidad frecuentes en Colombia. Se requieren estudios que caractericen la etiología de las deficiencias visuales permanentes. Objetivo: Identificar y caracterizar las diferentes causas de baja visión y ceguera en siete centros de referencia para la población con discapacidad visual en Colombia, atendida entre los años 2012 a 2017 en seis ciudades capitales. Materiales y métodos: estudio retrospectivo, serie de casos, descriptivo y multicéntrico. Resultados: Se contó con una muestra de 879 registros de pacientes con discapacidad visual. El 70% (612/879) con baja visión y 30% (267/879) con ceguera. Para todos los grupos de edad es más prevalente la baja visión. La etiología más frecuente en pacientes con baja visión fue la degeneración macular asociada a la edad (DMAE) (24%, 144/612); en pacientes con ceguera fue el glaucoma (17%, 45/267). Discusión: Posiblemente en Colombia las causas de baja visión y ceguera van más allá de las cataratas, errores de refracción no corregidos y ceguera infecciosa. Conclusiones: las etiologías más frecuentes encontradas son condiciones oculares crónicas y diversas, que requieren intervenciones específicas para disminuir su prevalencia y prevenir casos de baja visión y ceguera.

Novel Uses and Challenges of Artificial Intelligence in Diagnosing and Managing Eyes with High Myopia and Pathologic Myopia

Myopia is a global health issue, and the prevalence of high myopia has increased significantly in the past five to six decades. The high incidence of myopia and its vision-threatening course emphasize the need for automated methods to screen for high myopia and its serious form, named pathologic myopia (PM). Artificial intelligence (AI)-based applications have been extensively applied in medicine, and these applications have focused on analyzing ophthalmic images to diagnose the disease and to determine prognosis from these images. However, unlike diseases that mainly show pathologic changes in the fundus, high myopia and PM generate even more data because both the ophthalmic information and morphological changes in the retina and choroid need to be analyzed. In this review, we present how AI techniques have been used to diagnose and manage high myopia, PM, and other ocular diseases and discuss the current capacity of AI in assisting in preventing high myopia.

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.

Effect of Scleral Crosslinking Using Multiple Doses of Genipin on Experimental Progressive Myopia in Tree Shrews

Purpose

To evaluate the effect of scleral crosslinking (SXL) on slowing experimental progressive myopia in tree shrew eyes using sub-Tenon's injections of genipin (GEN) at different concentrations and number of injections.

Methods

Three or five sub-Tenon's injections of GEN at 0 mM (sham), 10 mM, or 20 mM were performed in one eye every other day starting at 18 days of visual experience. Form deprivation (FD) myopia was induced in the injected eye between 24 and 35 days of visual experience; the fellow eye served as control. Tree shrews were randomly assigned to five experimental groups: FD (n = 8); FD + 5 × sham injections (n = 6); FD + 3 × GEN injections at 10 mM (n = 6) and 20 mM (n = 6); and FD + 5 × GEN injections at 20 mM (n = 6). Refractive state and ocular dimensions were measured daily.

Results

Compared with the FD group, the sham-injected group showed a transient effect on slowing vitreous chamber elongation. With increasing GEN dose, SXL had an increasing treatment effect on slowing vitreous chamber elongation and myopia progression. In addition, SXL led to a dose-dependent shortening of the aqueous chamber depth and corneal thickening. Lens thickening was observed in the group with the highest concentration.

Conclusions

We have shown that SXL using GEN can slow axial elongation and myopia progression in tree shrews. The extent of this treatment effect was dose dependent. Several unexpected effects were observed (corneal thickening, decrease of the anterior chamber depth, and lens thickening), which require further optimization of the GEN delivery approach before clinical consideration.

Translational Relevance

The results of this preclinical study suggest that scleral crosslinking using genipin can slow myopia progression.

Machine learning prediction of pathologic myopia using tomographic elevation of the posterior sclera

Qualitative analysis of fundus photographs enables straightforward pattern recognition of advanced pathologic myopia. However, it has limitations in defining the classification of the degree or extent of early disease, such that it may be biased by subjective interpretation. In this study, we used the fovea, optic disc, and deepest point of the eye (DPE) as the three major markers (i.e., key indicators) of the posterior globe to quantify the relative tomographic elevation of the posterior sclera (TEPS). Using this quantitative index from eyes of 860 myopic patients, support vector machine based machine learning classifier predicted pathologic myopia an AUROC of 0.828, with 77.5% sensitivity and 88.07% specificity. Axial length and choroidal thickness, the existing quantitative indicator of pathologic myopia only reached an AUROC of 0.758, with 75.0% sensitivity and 76.61% specificity. When all six indices were applied (four TEPS, AxL, and SCT), the discriminative ability of the SVM model was excellent, demonstrating an AUROC of 0.868, with 80.0% sensitivity and 93.58% specificity. Our model provides an accurate modality for identification of patients with pathologic myopia and may help prioritize these patients for further treatment.

Deep Learning Approach for Automated Detection of Myopic Maculopathy and Pathologic Myopia in Fundus Images

PURPOSE

To determine whether eyes with pathologic myopia can be identified and whether each type of myopic maculopathy lesion on fundus photographs can be diagnosed by deep learning (DL) algorithms.

DESIGN

A DL algorithm was developed to recognize myopic maculopathy features and to categorize the myopic maculopathy automatically.

PARTICIPANTS

We examined 7020 fundus images from 4432 highly myopic eyes obtained from the Advanced Clinical Center for Myopia.

METHODS

Deep learning (DL) algorithms were developed to recognize the key features of myopic maculopathy with 5176 fundus images. These algorithms were also used to develop a Meta-analysis for Pathologic Myopia (META-PM) study categorizing system (CS) by adding a specific processing layer. Models and the system were evaluated by 1844 fundus image. The area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to determine the performance of each DL algorithm. The rate of correct predictions was used to determine the performance of the META-PM study CS.

MAIN OUTCOME MEASURES

Four trained DL models were able to recognize the lesions of myopic maculopathy accurately with high sensitivity and specificity. The META-PM study CS also showed a high accuracy and was qualified to be used in a semiautomated way during screening for myopic maculopathy in highly myopic eyes.

RESULTS

The sensitivity of the DL models was 84.44% for diffuse atrophy, 87.22% for patchy atrophy, 85.10% for macular atrophy, and 37.07% for choroidal neovascularization, and the AUC values were 0.970, 0.978, 0.982, and 0.881, respectively. The rate of total correct predictions from the META-PM study CS was 87.53%, with rates of 90.18%, 95.28%, 97.50%, and 91.14%, respectively, for each type of lesion. The META-PM study CS showed an overall rate of 92.08% in detecting pathologic myopia correctly, which was defined as having myopic maculopathy equal to or more serious than diffuse atrophy.

CONCLUSIONS

The novel DL models and system can achieve high sensitivity and specificity in identifying the different types of lesions of myopic maculopathy. These results will assist in the screening for pathologic myopia and subsequent protection of patients against low vision and blindness caused by myopic maculopathy.

Microperimetry as Part of Multimodal Assessment to Evaluate and Monitor Myopic Traction Maculopathy

Purpose

To characterize a population of high myopes with myopic traction maculopathy (MTM), to assess their retinal function, and to correlate it with anatomic status.

Patients and Methods

This was an observational cross-sectional study including 50 eyes from 27 patients. Demographic and clinical data were analyzed. Macular structure was assessed with spectral domain optical coherence tomography (SD-OCT, Heidelberg^®) and macular function was studied with Microperimeter MP-3, NIDEK^®.

Results

The average for central foveal thickness (CFT) and choroid thickness (CT) was 213±151 μm and 36±23 μm, respectively, in a total of 50 eyes from 27 patients. In the microperimetry analysis, the average sensitivity on the foveal-centered 12º polygon (CPS) was 14.37±9.1 dB. CT was negatively associated with the bivariate contour ellipse areas (BCEA) 1 (r=−0.314; p=0.034), 2 (r=−0.314; p=0.034), and 3 (r=−0.316; p=0.033). CPS had a strong positive correlation with best-corrected visual acuity (BCVA) (r=0.661; p=0.000). We found a trend to worse microperimetric results in eyes with schisis (n=19) (p>0.05) but eyes with atrophic areas (n=33) presented significant inferior CPS (p<0.001). The presence of staphyloma showed significant impact on macular sensitivities in eyes with areas of macular atrophy/fibrosis (p<0.05).

Conclusion

Macular microperimetry analysis can have a role as part of a multimodal anatomo-functional assessment for a more precise characterization of the high myopic patients with MTM, optimizing medical and surgical decisions.

Five-Year Incidence of Myopic Maculopathy in a General Japanese Population: The Hisayama Study

Importance

Myopic maculopathy is a leading cause of irreversible visual impairment worldwide. Moreover, the burden of myopic maculopathy has been expected to increase owing to the rising prevalence of myopia globally. However, there is limited epidemiologic evidence regarding the incidence of and risk factors for myopic maculopathy. This study from Japan, with a relatively high prevalence of myopia, could provide valuable information related to these issues.

Objective

To estimate the incidence of myopic maculopathy and its risk factors in Hisayama in southwestern Japan.

Design, Setting, and Participants

A population-based prospective cohort study in a Japanese community in Hisayama, Japan. The study included a total of 2164 residents 40 years or older who had no myopic maculopathy at the baseline eye examination in 2012 and underwent follow-up eye examinations in 2017.

Main Outcomes and Measures

Incidence of myopic maculopathy. The grades of myopic maculopathy were categorized based on the criteria of the Meta-analysis of Pathologic Myopia Study Group classification system.

Results

The mean (SD) age of the study participants was 62.4 (10.9) years, and the proportion of men was 42.5% (920 participants). In the follow-up examination in 2017, 24 patients developed myopic maculopathy. The 5-year cumulative incidence of myopic maculopathy was 1.1% (95% CI, 0.6-1.5) overall, 1.4% (95% CI, 0.6-2.2) for men, and 0.9% (95% CI, 0.4-1.4) for women. Multiple logistic regression analysis showed that older age (per 1 year; odds ratio [OR], 1.06; 95% CI, 1.01-1.11) and longer axial length (per 1 mm; OR, 2.94; 95% CI, 2.19-3.95) were associated with incident myopic maculopathy.

Conclusions and Relevance

Twenty-four study participants (1%) developed myopic maculopathy during the 5-year study period, which is much higher than the rate in a previous study on a Chinese population. We also confirmed that aging and longer axial length were independent and significant risk factors for myopic maculopathy. These findings should be reviewed among various populations in other parts of the world.

Reducing the Global Burden of Myopia by Delaying the Onset of Myopia and Reducing Myopic Progression in Children: The Academy's Task Force on Myopia

In 2019, the American Academy of Ophthalmology (AAO) created the Task Force on Myopia in recognition of the substantial global increases in myopia prevalence and its associated complications. The Task Force, led by Richard L. Abbott, MD, and Donald Tan, MD, comprised recognized experts in myopia prevention and treatment, public health experts from around the world, and organization representatives from the American Academy of Family Physicians, American Academy of Optometry, and American Academy of Pediatrics. The Academy's Board of Trustees believes that myopia is a high-priority cause of visual impairment, warranting a timely evaluation and synthesis of the scientific literature and formulation of an action plan to address the issue from different perspectives. This includes education of physicians and other health care providers, patients and their families, schools, and local and national public health agencies; defining health policies to ameliorate patients' access to appropriate therapy and to promote effective public health interventions; and fostering promising avenues of research.

Cilioretinal Arteries in Highly Myopic Eyes: A Photographic Classification System and Its Association With Myopic Macular Degeneration

Purpose: To develop a photographic classification for cilioretinal arteries and to investigate its association with myopic macular degeneration (MMD).

Methods: One thousand six hundred ninety-two highly myopic eyes of 1,692 patients were included. The presence of a cilioretinal artery was determined by fundus photographs, and a photographic classification was proposed. MMD was classified according to the International META-PM Classification. Associations of the cilioretinal artery and its classifications with MMD and visual acuity were analyzed.

Results: Of the eyes tested, 245 (14.5%) had a cilioretinal artery. The cilioretinal arteries were classified into four categories (temporal “cake-fork,” 35.92%; temporal “ribbon,” 53.47%; “multiple,” 6.53%; “nasal,” 4.08%) and 3 distributions based on whether its visible branches reached the central foveal area. Eyes with cilioretinal arteries had significantly less MMD of grade ≥3 and better visual acuity than those without (P < 0.01). Multiple linear regression analysis showed that younger age, male sex, shorter axial length, and the presence of a cilioretinal artery were associated with better visual acuity in highly myopic eyes (all P < 0.05). The “nasal” category presented more MMD with grade ≥3 and worse visual acuity than the other categories (P < 0.05), whereas the “multiple” category contained no eyes with MMD grade ≥3. The cilioretinal arteries reaching the central foveal area showed less MMD of grade ≥3 and better visual acuity than those not (P < 0.05).

Conclusions: We propose a photographic classification for cilioretinal arteries that has good clinical relevance to visual functions. The cilioretinal artery may potentially afford protection against MMD.

The Prevalence and Causes of Visual Impairment in Type 2 Diabetes Mellitus in Northeast China

Purpose

To evaluate the prevalence and causes of visual impairment in a group of community people with type 2 diabetes mellitus (T2DM) in Northeast China.

Methods

Population-based cross-sectional survey. Patients diagnosed with T2DM residing in 15 communities in Fushun, Northeast China, were enrolled between July 2012 and May 2013. All participants underwent an extensive and standardized eye examination (visual acuity testing, slit-lamp, and fundus examination). Low vision was defined as presenting VA of better-seeing eye <20/60 and ≥20/400, and blindness was defined as VA <20/400, according to the World Health Organization (WHO) definitions. The primary causes of blindness and low vision were assessed by senior ophthalmologists.

Results

Visual acuity measurements were available for 1998 (89.8%) of 2224 subjects in the study. The prevalence of bilateral blindness and low vision defined was 0.90% and 10.81%. Uncorrected refractive error was the first leading cause of low vision (75.0%) and blindness (38.9%). After correcting the refractive error, the first leading cause of low vision was cataract (44.4%), followed by diabetic retinopathy (29.6%) and myopic maculopathy (18.5%), while the first leading cause of blindness was proliferative DR (45.4%), followed by cataract (36.4%) and myopic maculopathy (18.2%).

Conclusions

This study suggested a high prevalence of low vision and blindness in this study cohort. Uncorrected refractive error and cataract remain the leading cause of visual impairment, but the major challenge is the early diagnosis and intervention of diabetic retinopathy to reduce diabetes-related blindness.

The prevalence and causes of visual impairment among ethnic Tujia adults in a rural community in China

We aimed to investigate the prevalence and causes of visual impairment (VI) in an elderly Tujia ethnic rural population in Southwest China.From June 1 to December 31, 2018, a random cluster sampling survey was conducted among Tujia individuals aged 50 years or older in the rural areas of Qianjiang District County in Chongqing. The sampling design used village-based clusters of approximately equal size (1000 people). The sampling frame was composed of 110 clusters including 26,527 adults aged 50 years or older; 10 clusters (2556 adults) were randomly selected, and 2122 subjects were examined. Ophthalmologic examinations and questionnaires were administered to all the participants. Low vision and blindness were defined using best-corrected visual acuity (BCVA) and presenting visual acuity, according to The World Health Organization standard. The prevalence of VI was estimated, and causes of VI were identified.The participation rate was 83.0%. The prevalence of VI was 15.2% (BCVA 8.0%). In the study population, the prevalence of low vision and blindness increased with age (P < .05) and was higher among those with a low education level (P < .01). The majority of VI was attributed to cataracts (50.0%) and uncorrected refractive error (35.7%). With BCVA, cataract (79.3%) was the most common cause of VI, followed by age-related macular degeneration (10.7%).The main causes of VI in Tujia ethnic were cataracts and refractive errors. Both cataracts and refractive errors are curable eye diseases; thus, local health institutions need to adopt a more active eye care project as a strategy to prevent blindness.

Anterior Sclera Undergoes Thinning with Increasing Degree of Myopia

Purpose

Considering that ocular expansion is associated with scleral thinning, this study investigated variation in scleral thickness (anterior scleral thickness [AST] and posterior scleral thickness [PST]) in different meridians across emmetropes and a wide range of myopes.

Methods

A total of 95 participants (mean age, 24 ± 4 years) including emmetropes (spherical equivalent refractive error, ±0.75 diopters [D]; n = 20) and myopes (-1.00 to -27.25 D; n = 75) underwent ocular imaging with swept-source optical coherence tomography. All the images were analyzed using semiautomated custom-designed software to determine scleral thickness in 1-mm intervals. AST was estimated from limbus to 5 mm (n = 95), and PST from fovea to 5 mm (n = 25; high myopes only) along the horizontal and vertical meridian.

Results

The median spherical equivalent refractive error and axial length were -4.25 D (IQR, -12.50 to -1.00 D) and 25 mm (IQR, 23.72-28.35 mm), respectively. The anterior sclera was thinnest in the superior and thickest in the inferior region (475.3 ± 19.0 vs. 605.9 ± 18.6 µm; P < 0.001). The inferior AST alone decreased significantly with increasing magnitude of myopia (r = 0.27; P = 0.008). There were no differences in AST between nasal and temporal meridians (583.24 ± 15.00 vs. 587.09 ± 27.00 µm; P > 0.05). The mean subfoveal PST for the subset of high myopes was 251.7 ± 12.0 µm which was thinner than mean AST along all the meridians by more than 45%. The averaged scleral thickness peripheral to fovea (1-5 mm) was similar along different meridians (P > 0.05).

Conclusions

The relative significant thinning of the anterior sclera along the inferior meridian with increasing degree of myopia compared with the other three meridians indicates the potential role of AST, especially in the inferior meridian, to act as a marker for myopia progression.

Natural course of the intraretinal hyperreflective sign after macular haemorrhage absorption in eyes with pathologic myopia

PURPOSE

We investigated the natural course of the intraretinal hyperreflective (IRH) sign after macular haemorrhage (MHE) absorption in eyes with pathologic myopia.

METHODS

This prospective observational cohort study evaluated 28 patients with pathologic myopia and MHE. The eyes were categorized into IRH and non-IRH sign groups according to IRH sign development. All eyes were evaluated; follow-up visits were scheduled at 1, 3, 6, 12 and 24 months after MHE absorption.

RESULTS

Of 28 patients (14 eyes each in the IRH and non-IRH groups), nine (32.1%) were men and 19 (67.9%) were women. The average age (mean ± SD) was 46.64 ± 11.92 versus 52.71 ± 12.19 years in the IRH and non-IRH groups. The IRH sign coincided with the MHE invasion site. The sign persisted for the entire follow-up period in all but two eyes, in which it disappeared at 12 and 24 months, respectively. Maximal MHE thickness was significantly greater in the IRH sign group (162.9 ± 67.84 versus 104.2 ± 32.34 μm, p = 0.013). The mean logarithm of the minimum angle of resolution visual acuity was significantly better in the non-IRH sign group at 12 (p = 0.029) and 24 (p = 0.033) months. The incidence of myopic traction maculopathies (MTM) was significantly higher in the IRH (57.1%) than in the non-IRH sign group (14.3%; p = 0.046).

CONCLUSION

The IRH sign can develop after MHE in pathologic myopia and can remain stable long after MHE absorption; furthermore, it is predictive of future MTM.

Cilioretinal Arteries and Macular Vasculature in Highly Myopic Eyes: An OCT Angiography-Based Study

PURPOSE

To determine the association between the presence of cilioretinal arteries and the macular vasculature in highly myopic eyes using OCT angiography (OCTA).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Four hundred eighty-one highly myopic eyes of 481 patients.

METHODS

Fundus photographs were reviewed to determine the presence of a cilioretinal artery and its distribution, based on whether its path or visible branches reached the region within 500 μm of the foveal center. The macular vasculature was analyzed in OCTA images, including the vessel density (VD), fractal dimension (FD), and foveal avascular zone (FAZ). The associations between the presence of a cilioretinal artery and its distribution and between the macular vasculature and visual acuity were evaluated.

MAIN OUTCOME MEASURES

Cilioretinal arteries, macular vasculature, and their associations.

RESULTS

Of the eyes included, 17.05% (82/481) had a cilioretinal artery. Based on the OCTA analysis, the eyes with cilioretinal arteries showed significantly higher VD and FD in both superficial and deep capillary plexuses and smaller FAZ than those without (all P < 0.001). However, these differences were not found in the subgroup of eyes with an axial length of more than 30 mm. Eyes with cilioretinal arteries that reached the central foveal area showed significantly higher VD and FD in both capillary plexuses and smaller FAZ than those that did not (all P < 0.05). Better best-corrected visual acuity was identified in the eyes with cilioretinal arteries than in those without (0.09 ± 0.14 logarithm of the minimum angle of resolution [logMAR] vs. 0.21 ± 0.27 logMAR, respectively; P < 0.001). In particular, eyes with cilioretinal arteries that reached the central foveal area had better visual acuity than those without (0.05 ± 0.06 logMAR vs. 0.16 ± 0.20logMAR, respectively; P = 0.005).

CONCLUSIONS

This OCTA-based study suggested that cilioretinal arteries in highly myopic eyes potentially may improve the macular vasculature and influence visual function.

Prevalence and causes of visual impairment in population more than 50 years old: The Shaanxi Eye Study

To assess the prevalence and causes of visual impairment (VI) in the elderly Chinese rural population in Shaanxi Province.A population-based, cross-sectional study design was used to determine the extent of VI in Chinese people over the age of 50 years in Shaanxi Province. Visual acuity and best-corrected visual acuity were measured using the logarithm of minimum angle of resolution chart. Blindness and low vision were defined according to WHO criteria. The major cause of VI was identified for all participants who were visually impaired.A total of 1912 residents completed a standard questionnaire and underwent a detailed eye examination, and the response rate was 90%. The overall prevalence of blindness and low vision were 1.5% and 8.2%. There was no statistically significant differences between genders in the prevalence of blindness and low vision (P > .05). The prevalence of blindness and low vision was higher among older individuals (P < .05) and lower (P < .05) among those with the highest education level. Cataract, corneal opacity, and glaucoma were considered as the main causes of blindness, which accounted for 67.9%, 10.7%, and 7.1%, respectively. Cataract, refractive error, and age-related macular degeneration were always considered as the leading causes of low vision, which accounted for 66%, 14.7%, and 5.8%, respectively.Cataract, corneal opacity, and glaucoma were the main causes of blindness and low vision in the population aged 50 years or more. The prevalence of these diseases that causes blindness and low vision was higher than that reported in other studies.

Patchy Scotoma Observed in Chorioretinal Patchy Atrophy of Myopic Macular Degeneration

Purpose

To investigate the retinal sensitivity of highly myopic eyes with chorioretinal patchy atrophy (PA) using microperimetry.

Methods

Fifty-two eyes of 32 patients with high myopia were prospectively included. Twenty-two eyes of 16 patients had PA lesions; eyes without PA were analyzed as controls. Testing points on microperimetry in eyes with PA were designated as 3 zones: zone 1 as the PA lesion including its borders; zone 2 including testing points adjoining PA; zone 3 including all other testing points.

Results

In the PA group, the mean retinal sensitivity in zone 1 was 2.1 ± 2.8 dB, zone 2 = 8.3 ± 4.3 dB, and zone 3 = 9.4 ± 4.1 dB. Sensitivity in zone 1 was significantly reduced than zones 2 and 3 (P < 0.001). The mean retinal sensitivity in the PA group was lower than controls (6.5 ± 4.3 vs 13.9 ± 4.1 dB, P < 0.001), and combined zone 2 and 3 in the PA group also presented lower retinal sensitivity (8.8 ± 4.0 dB).

Conclusions

Eyes with PA generate patchy scotoma in PA lesions and reduced retinal sensitivity in regions beyond atrophic lesion on microperimetry. The presence of PA may be an indicator to reflect both significantly anatomical and functional alterations on myopic macular degeneration.

Risk Factors and Behaviours of Schoolchildren with Myopia in Taiwan

Importance: Because of the high prevalence of myopia in Taiwan, understanding the risk factors for its development and progression is important to public health. Background: This study investigated the risk factors for myopia and their influence on the progression of myopia in schoolchildren in Taiwan. Design: Patients’ clinical records were obtained retrospectively from ophthalmologists. Questionnaires were given to collect demographic information, family background, hours spent on daily activities, myopia progression, and treatment methods. Participants: From a regional medical hospital in northern Taiwan, 522 schoolchildren with myopia participated in the study. Written informed consent was obtained from participants of legal age or the parents or legal guardians of younger children. Methods: Multivariable regression analyses were performed. Myopia measured in cycloplegic spherical equivalent (SE) was analysed, controlling for patients’ family and demographic information as well as their daily activity behaviours. Main Outcome Results: Children with high myopic parents were more myopic. Earlier onset age of myopia was associated with a higher level of myopia and greater annual myopic progression. Children reporting longer time usage of electronic devices had greater progression of myopia. Boys tended to be more myopic than girls. Lower levels of myopia were associated with more outdoor activities, and better vision care knowledge in children and parents. Conclusions and Relevance: In addition to genetics, education and environment can influence the development of myopia. Health policies for schoolchildren should promote protective activities and vision care knowledge at a young age, to protect the eyesight of schoolchildren.

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.

Trends in the Prevalence of Myopia and Myopic Maculopathy in a Japanese Population: The Hisayama Study

Purpose

To examine trends in the prevalence of myopia and myopic maculopathy in a general Japanese population.

Methods

Residents of a Japanese community aged 40 years and older participated in surveys conducted in 2005, 2012, and 2017. Each participant underwent comprehensive eye examinations that included measurements of refractive error, axial lengths, and color fundus photography. Myopic maculopathy was defined according to the criteria of the Meta-analysis of Pathologic Myopia Study Group classification system. Trends in the prevalence of myopia and myopic maculopathy were tested by using a logistic regression analysis fitted by generalized estimating equations to account for individuals submitting to repeated examination.

Results

The age-adjusted frequencies of myopia increased significantly from 2005 to 2017 (myopia, 37.7%-45.8%; high myopia 5.8%-9.5%; all P for trend <0.001). The age-adjusted frequency of an axial length level of 26.5 mm or more increased significantly from 2005 to 2017 (3.6%-6.0%; P for trend <0.001). The age-adjusted prevalence of myopic maculopathy also increased significantly with time (1.6% in 2005, 3.0% in 2012 and 3.6% in 2017; P for trend <0.001). Upward trends were observed in the prevalence of diffuse chorioretinal atrophy and patchy chorioretinal atrophy (all P for trend <0.05).

Conclusions

Our findings suggest that the prevalence of myopia and myopic maculopathy, especially diffuse chorioretinal atrophy and patchy chorioretinal atrophy, increased significantly over the past 12 years in a general Japanese population.

Accommodation and its role in myopia progression and control with soft contact lenses

PURPOSE

To examine the impact of contact lens optical design on accommodative behaviour of children and the correlation between myopia progression and the accommodative response of the eye while wearing a contact lens designed for myopia control.

METHODS

A post-hoc analysis was conducted on data from a previously published myopia control trial. A total of 109 subjects (aged 8 to 11 years, myopia: -0.75 to -4.00 D) wore either a Control (single-vision, n = 57) or a Test (with positive spherical aberration, +SA, n = 52) soft contact lens, binocularly for 1 year. Accommodative response was measured as the subject observed targets at -1.00 to -4.00 D vergence using the Grand Seiko WAM-5500 open-field autorefractor (www.grandseiko.com). Slope of accommodative response (SAR) as well as distance and near phoria and stimulus accommodative convergence/accommodation (AC/A) were compared between each group at baseline without study lenses and at 1-week and 1-year visits with study lenses. The SAR was also compared to changes in axial length (AL) and spherical equivalent cycloplegic auto refraction (SECAR).

RESULTS

At baseline, there was no significant difference in SAR between the two study groups (ΔSAR = -0.039, p = 0.84). At 1 week, mean SAR of the Test group was significantly less than for the Control group (ΔSAR = -0.203, p < 0.0001), an effect that persisted to 1 year (ΔSAR = -0.129, p < 0.0001). In the Test group, greater SAR was associated with less change in AL (regression coefficient: -0.59 mm, p < 0.0001) and SECAR (regression coefficient: 1.12 D, p = 0.006) at 1 year. In the Control group, associations between SAR and change in AL and SECAR were not statistically significant. Compared to the Control group, eyes of the Test group appeared to be more exophoric with study lenses, however, the difference between the two groups was only significant at 1 week for distance phoria and 1 year for near phoria.

CONCLUSION

The soft contact lens with +SA for controlling myopia progression resulted in an apparent decrease in mean accommodation. Within the Test group, reduced accommodative response correlated with greater myopia progression, suggesting some subjects in the Test group utilised the +SA for near viewing, inducing hyperopic defocus at the retina. Accordingly, the potential impact of a lens optics on accommodative function should be considered during design of myopia control lenses.

Scleral structure and biomechanics

As the eye's main load-bearing connective tissue, the sclera is centrally important to vision. In addition to cooperatively maintaining refractive status with the cornea, the sclera must also provide stable mechanical support to vulnerable internal ocular structures such as the retina and optic nerve head. Moreover, it must achieve this under complex, dynamic loading conditions imposed by eye movements and fluid pressures. Recent years have seen significant advances in our knowledge of scleral biomechanics, its modulation with ageing and disease, and their relationship to the hierarchical structure of the collagen-rich scleral extracellular matrix (ECM) and its resident cells. This review focuses on notable recent structural and biomechanical studies, setting their findings in the context of the wider scleral literature. It reviews recent progress in the development of scattering and bioimaging methods to resolve scleral ECM structure at multiple scales. In vivo and ex vivo experimental methods to characterise scleral biomechanics are explored, along with computational techniques that combine structural and biomechanical data to simulate ocular behaviour and extract tissue material properties. Studies into alterations of scleral structure and biomechanics in myopia and glaucoma are presented, and their results reconciled with associated findings on changes in the ageing eye. Finally, new developments in scleral surgery and emerging minimally invasive therapies are highlighted that could offer new hope in the fight against escalating scleral-related vision disorder worldwide.

Experimental myopia increases and scleral crosslinking using genipin inhibits cyclic softening in the tree shrew sclera

PURPOSE

Myopia progression is thought to involve biomechanical weakening of the sclera, which leads to irreversible deformations and axial elongation of the eye. Scleral crosslinking has been proposed as a potential treatment option for myopia control by strengthening the mechanically weakened sclera. The biomechanical mechanism by which the sclera weakens during myopia and strengthens after crosslinking is not fully understood. Here, we assess the effect of lens-induced myopia and exogenous crosslinking using genipin on the inelastic mechanical properties of the tree shrew sclera measured by cyclic tensile tests.

METHODS

Cyclic tensile tests were performed on 2-mm wide scleral strips at physiological loading conditions (50 cycles, 0-3.3 g, 30 s cycle^-1 ). Two scleral strips were obtained from each eye of juvenile tree shrews exposed to two different visual conditions: normal and 4 days of monocular -5 D lens wear to accelerate scleral remodelling and induce myopia. Scleral strips were mechanically tested at three alternative conditions: immediately after enucleation; after incubation in phosphate buffered saline (PBS) for 24 h at 37°C; and after incubation for 24 h in PBS supplemented with genipin at a low cytotoxicity concentration (0.25 mm). Cyclic softening was defined as the incremental strain increase from one cycle to the next.

RESULTS

-5D lens treatment significantly increased the cyclic softening response of the sclera when compared to contralateral control eyes (0.10% ± 0.029%, mean ± standard error, P = 0.037). Exogenous crosslinking of the lens treated sclera significantly decreased the cyclic softening response (-0.12% ± 0.014%, P = 2.2 × 10^-5 ). Contrary to all other groups, the genipin-cross-linked tissue did not exhibit cyclic softening significantly different from zero within the 50-cycle test.

CONCLUSIONS

Results indicated that cyclic tensile loading leads to an inelastic, cyclic softening of the juvenile tree shrew sclera. The softening rate increased during lens-induced myopia and was diminished after genipin crosslinking. This finding suggests that axial elongation in myopia may involve a biomechanical weakening mechanism that increased the cyclic softening response of the sclera, which was inhibited by scleral crosslinking using genipin.

Five-year incidence and progression of myopic maculopathy in a rural Chinese adult population: the Handan Eye Study

PURPOSE

To determine the cumulative five-year incidence and progression of myopic maculopathy in a rural Chinese adult population.

METHODS

The Handan Eye Study was a population-based longitudinal study. In 2006, 6830 subjects aged 30+ years participated in this study (baseline). Five years later, 5394 subjects (follow-up rate: 85.3%) took part in the follow-up study. Participants had a detailed eye examination, including visual acuity, standardized refraction and fundus photography according to a similar protocol at both baseline and follow-up. Myopic maculopathy was defined as any of the following signs: diffuse chorioretinal atrophy, patchy chorioretinal atrophy, macular atrophy, lacquer cracks and myopic choroidal neovascularization at the posterior pole. Parapapillary atrophy was assessed separately.

RESULTS

Of 5394 participants, 5078 (10 021 eyes) had gradable fundus photographs. Over the five years, four participants (five eyes) developed new myopic maculopathy, with an eye-specific incidence of 0.05% (95% CI, 0.02-0.10%). Among the 51 eyes with myopic maculopathy at baseline, the progression occurred in 18 eyes (35.3%), with new signs of patchy chorioretinal atrophy in 11 eyes (21.6%), diffuse chorioretinal atrophy in seven eyes (13.7%), lacquer cracks in three eyes (6.9%), macular atrophy in three eyes (6.9%) and myopic choroidal neovascularization in two eyes (3.9%). By multivariable analysis, female gender (OR, 9.14; p = 0.004) and higher educational level (OR, 8.24; p = 0.004) were associated with a higher risk of progression of myopic maculopathy, whereas lower myopia at baseline (OR, 0.79; p < 0.0001) and hypertension (OR, 0.21; p = 0.017) were associated with a reduced risk.

CONCLUSIONS

The five-year incidence of myopic maculopathy was 0.05% in rural Chinese adults aged 30+ years. The progression rate in participants with myopic maculopathy was 35.3%, indicating the importance of regular follow-up for these patients.

Myopic maculopathy: Current status and proposal for a new classification and grading system (ATN)

Myopia is a highly frequent ocular disorder worldwide and pathologic myopia is the 4th most common cause of irreversible blindness in developed countries. Pathologic myopia is especially common in East Asian countries. Ocular alterations associated with pathologic myopia, especially those involving the macular area-defined as myopic maculopathy-are the leading causes of vision loss in patients with pathologic myopia. High myopia is defined as the presence of a highly negative refractive error (>-6 to -8 diopters) in the context of eye elongation (26-26.5 mm). Although the terms high myopia and pathologic myopia are often used interchangeably, they do not refer to the same eye disease. The two key factors driving the development of pathologic myopia are: 1) elongation of the axial length and 2) posterior staphyloma. The presence of posterior staphyloma, which is the most common finding in patients with pathologic myopia, is the key differentiating factor between high and pathologic myopia. The occurrence of staphyloma will, in most cases, eventually lead to other conditions such as atrophic, traction, or neovascular maculopathy. Posterior staphyloma is for instance, responsible for the differences between a myopic macular hole (MH)-with and without retinal detachment-and idiopathic MH. Posterior staphyloma typically induces retinal layer splitting, leading to foveoschisis in myopic MH, an important differentiating factor between myopic and emmetropic MH. Myopic maculopathy is a highly complex disease and current classification systems do not fully account for the numerous changes that occur in the macula of these patients. Therefore, a more comprehensive classification system is needed, for several important reasons. First, to more precisely define the disease stage to improve follow-up by enabling clinicians to more accurately monitor changes over time, which is essential given the progressive nature of this condition. Second, unification of the currently-available classification systems would establish standardized classification criteria that could be used to compare the findings from international multicentric studies. Finally, a more comprehensive classification system could help to improve our understanding of the genetic origins of this disease, which is clearly relevant given the interchangeable-but erroneous-use of the terms high and pathologic myopia in genetic research.

Diagnosis and Treatment of Myopic Maculopathy

Visual impairment resulting from pathologic myopia is a serious issue worldwide. This is mainly due to the development of different types of myopic maculopathy. Despite being a major cause of visual impairment worldwide, myopic maculopathy was not consistently defined. To overcome this problem, in 2015 the Meta-Analysis for Pathologic Myopia Study Group proposed a simplified, uniform classification system for myopic maculopathy. Among several lesions of myopic maculopathy, myopic choroidal neovascularization (CNV) is one of the most common and severe vision-threatening complications. Recent large clinical trials have reported a good initial efficacy for visual acuity improvement by application of anti-vascular endothelial growth factor therapy for myopic CNVs. However, long-term clinical studies demonstrate a gradual decrease in the visual acuity gain and return to the baseline level due to the development of myopic CNV-related macular atrophy. Regarding visual impairment caused by advanced myopic chorioretinal atrophy, the only way to prevent blindness is to prevent myopia from developing or progressing at a young age before the axial length elongates extremely. As peripapillary diffuse atrophy in childhood may be an indicator of more advanced myopic chorioretinal atrophy in later life, some preventive measures should be considered in such children.

Patterns of posterior ocular complications in myopic eyes of Indian population

This is a retrospective study aimed to investigate the patterns of myopic fundus complications in Indian children and young adults. Electronic medical records of 29,592 patients, aged 10–40 years, who visited L V Prasad Eye Institute between 1^st January to 31^st December 2016 were analysed in the study. Data such as age, gender, refractive error and various pathologic lesions of posterior globe were considered for analysis. Among all the patients with different types of refractive errors, myopia was found in 47.4%, high myopia in 6.8% and pathologic myopia in 2.2%. There was no trend of the increased prevalence of pathologic myopia with increasing age, except for a significant difference between the children aged 10–15 years (2.7%) and those aged more than 15 years (>4%). . Although, the overall pattern of pathologic lesions was similar across different grades of myopia (2.5% in low myopes vs. 2.2% in severe myopes), lesions like staphyloma and retinal detachment increased with increasing degree of myopia. The proportion of pathologic lesions across different grades of myopia suggests the necessity for careful peripheral fundus examinations irrespective of the degree of myopia for better management and prognostic purposes.

Short term optical defocus perturbs normal developmental shifts in retina/RPE protein abundance

BACKGROUND

Myopia (short-sightedness) affects approximately 1.4 billion people worldwide, and prevalence is increasing. Animal models induced by defocusing lenses show striking similarity with human myopia in terms of morphology and the implicated genetic pathways. Less is known about proteome changes in animals. Thus, the present study aimed to improve understanding of protein pathway responses to lens defocus, with an emphasis on relating expression changes to no lens control development and identifying bidirectional and/or distinct pathways across myopia and hyperopia (long-sightedness) models.

RESULTS

Quantitative label-free proteomics and gene set enrichment analysis (GSEA) were used to examine protein pathway expression in the retina/RPE of chicks following 6 h and 48 h of myopia induction with - 10 dioptre (D) lenses, hyperopia induction with +10D lenses, or normal no lens rearing. Seventy-one pathways linked to cell development and neuronal maturation were differentially enriched between 6 and 48 h in no lens chicks. The majority of these normal developmental changes were disrupted by lens-wear (47 of 71 pathways), however, only 11 pathways displayed distinct expression profiles across the lens conditions. Most notably, negative lens-wear induced up-regulation of proteins involved in ATP-driven ion transport, calcium homeostasis, and GABA signalling between 6 and 48 h, while the same proteins were down-regulated over time in normally developing chicks. Glutamate and bicarbonate/chloride transporters were also down-regulated over time in normally developing chicks, and positive lens-wear inhibited this down-regulation.

CONCLUSIONS

The chick retina/RPE proteome undergoes extensive pathway expression shifts during normal development. Most of these pathways are further disrupted by lens-wear. The identified expression patterns suggest close interactions between neurotransmission (as exemplified by increased GABA receptor and synaptic protein expression), cellular ion homeostasis, and associated energy resources during myopia induction. We have also provided novel evidence for changes to SLC-mediated transmembrane transport during hyperopia induction, with potential implications for signalling at the photoreceptor-bipolar synapse. These findings reflect a key role for perturbed neurotransmission and ionic homeostasis in optically-induced refractive errors, and are predicted by our Retinal Ion Driven Efflux (RIDE) model.

The Adenosine Receptor Antagonist, 7-Methylxanthine, Alters Emmetropizing Responses in Infant Macaques

Purpose

Previous studies suggest that the adenosine receptor antagonist, 7-methylxanthine (7-MX), retards myopia progression. Our aim was to determine whether 7-MX alters the compensating refractive changes produced by defocus in rhesus monkeys.

Methods

Starting at age 3 weeks, monkeys were reared with −3 diopter (D; n = 10; 7-MX −3D/pl) or +3D (n = 6; 7-MX +3D/pl) spectacles over their treated eyes and zero-powered lenses over their fellow eyes. In addition, they were given 100 mg/kg of 7-MX orally twice daily throughout the lens-rearing period (age 147 ± 4 days). Comparison data were obtained from lens-reared controls (−3D/pl, n = 17; +3D/pl, n = 9) and normal monkeys (n = 37) maintained on a standard diet. Refractive status, corneal power, and axial dimensions were assessed biweekly.

Results

The −3D/pl and +3D/pl lens-reared controls developed compensating myopic (−2.10 ± 1.07 D) and hyperopic anisometropias (+1.86 ± 0.54 D), respectively. While the 7-MX +3D/pl monkeys developed hyperopic anisometropias (+1.79 ± 1.11 D) that were similar to those observed in +3D/pl controls, the 7-MX −3D/pl animals did not consistently exhibit compensating myopia in their treated eyes and were on average isometropic (+0.35 ± 1.96 D). The median refractive errors for both eyes of the 7-MX −3D/pl (+5.47 D and +4.38 D) and 7-MX +3D/pl (+5.28 and +3.84 D) monkeys were significantly more hyperopic than that for normal monkeys (+2.47 D). These 7-MX–induced hyperopic ametropias were associated with shorter vitreous chambers and thicker choroids.

Conclusions

In primates, 7-MX reduced the axial myopia produced by hyperopic defocus, augmented hyperopic shifts in response to myopic defocus, and induced hyperopia in control eyes. The results suggest that 7-MX has therapeutic potential in efforts to slow myopia progression.

CCDC102B confers risk of low vision and blindness in high myopia

The incidence of high myopia is increasing worldwide with myopic maculopathy, a complication of myopia, often progressing to blindness. Our two-stage genome-wide association study of myopic maculopathy identifies a susceptibility locus at rs11873439 in an intron of CCDC102B (P = 1.77 × 10⁻¹² and P_corr = 1.61 × 10⁻¹⁰). In contrast, this SNP is not significantly associated with myopia itself. The association between rs11873439 and myopic maculopathy is further confirmed in 2317 highly myopic patients (P = 2.40 × 10⁻⁶ and P_corr = 1.72 × 10⁻⁴). CCDC102B is strongly expressed in the retinal pigment epithelium and choroids, where atrophic changes initially occur in myopic maculopathy. The development of myopic maculopathy thus likely exhibits a unique background apart from the development of myopia itself; elucidation of the roles of CCDC102B in myopic maculopathy development may thus provide insights into preventive methods for blindness in patients with high myopia.

Myopic maculopathy is a complication of myopia that often progresses to blindness. Here, in a genome-wide association study, Hosoda et al. find that rs11873439 intronic to CCDC102B is associated with myopic maculopathy, but not with myopia, thus representing a risk factor independent of myopia.

Progression of Myopic Maculopathy during 18-Year Follow-up

PURPOSE

To examine the progression pattern of myopic maculopathy.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Highly myopic patients who had been followed up for 10 years or more.

METHODS

Using fundus photographs, myopic features were differentiated according to Meta-analysis of Pathologic Myopia (META-PM) Study Group recommendations.

MAIN OUTCOME MEASURES

Progression pattern of maculopathy.

RESULTS

The study included 810 eyes of 432 patients (mean age, 42.3±16.8 years; mean axial length, 28.8±1.9 mm; mean follow-up, 18.7±7.1 years). The progression rate of myopic maculopathy was 47.0 per 1000 eye-years. Within the pathologic myopia (PM) group (n = 521 eyes), progression of myopic maculopathy was associated with female gender (odds ratio [OR], 2.21; P = 0.001), older age (OR, 1.03; P = 0.002), longer axial length (OR, 1.20; P = 0.007), greater axial elongation (OR, 1.45; P = 0.005), and development of parapapillary atrophy (PPA; OR, 3.14; P < 0.001). Diffuse atrophy, found in 217 eyes without choroidal neovascularization (CNV) or lacquer cracks (LCs) at baseline, progressed in 111 (51%) eyes, leading to macular diffuse atrophy (n = 64; 64/111 or 58%), patchy atrophy (n = 59; 53%), myopic CNV (n = 18; 16%), LCs (n = 9; 5%), and patchy-related macular atrophy (n = 3; 3%). Patchy atrophy, detected in 63 eyes without CNV or LCs at baseline, showed progression in 60 eyes (95%), leading to enlargement of original patchy atrophy (n = 59; 59/60 or 98%), new patchy atrophy (n = 29; 48%), CNV-related macular atrophy (n = 13; 22%), and patchy-related macular atrophy (n = 5; 8%). Of 66 eyes with LCs, 43 eyes (65%) showed progression with development of new patchy atrophy (n = 38; 38/43 or 88%) and new LCs (n = 7; 16%). Reduction in best-corrected visual acuity (BCVA) was associated mainly (all P < 0.001) with the development of CNV or CNV-related macular atrophy and enlargement of macular atrophy.

CONCLUSIONS

The most frequent progression patterns were an extension of peripapillary diffuse atrophy to macular diffuse atrophy in diffuse atrophy, enlargement of the original atrophic lesion in patchy atrophy, and development of patchy atrophy in LCs. Main risk factors for progression were older age, longer axial length, and development of PPA.

Eye Health Information Systems in Selected Countries

One of the important factors for achieving “Vision 2020” targets is the availability and accessibility of eye health information systems. This study aimed to describe eye health information systems in selected countries. The status of eye health information systems in Australia, the United States, and England was reviewed. Data were gathered from the PubMed, Scopus, and ScienceDirect databases. The main key terms used included, but were not limited to “National Action plan”, “Eye Health Information System”, “Database”, and “Registery”. Also, the websites of the World Health Organization, the International Agency for the Prevention of Blindness, and Departments of Health in the selected countries were accessed. Fifty documents and articles of 170 retrieved references related to the research goals were used in this study. In all three countries, the issue of eye health is considered to be a national health priority. Concerning data gathering, the most common point in these countries was data gathered directly (health information systems, eye registries) and indirectly (studies, projects, and surveillance systems) by the organizations that participated in eye health programs. Producing accessible, timely, and highly quality information about eye health is one of the most important goals in the formation of eye health information systems in the selected countries, which facilitates achievement of the goals of the “Vision 2020: The Right to Sight” initiative.

Multimodal imaging of linear lesions in the fundus of pathologic myopic eyes with macular lesions

PURPOSE

To detect, using multimodal imaging, lacquer cracks (LCs) and myopic stretch lines (MSLs) in pathologic myopic eyes with macular hemorrhage (MHE) and those without.

METHODS

We collected 18 consecutive pathologic myopic eyes (spherical equivalent ≤ -8.0 diopters) that had presented with linear, yellowish-white lesions in the macula. We categorized the eyes into either the MHE group or the non-MHE group. All underwent fluorescein angiography (FA), near infrared autofluorescence (NIA), indocyanine green angiography (ICGA), and spectral-domain optical coherence tomography (SD-OCT).

RESULTS

In all 18 eyes, the linear lesions were hyperfluorescent under NIA imaging, but hypofluorescent under ICGA. All ten eyes in the MHE group had LCs, and two had both LCs and MSLs. None of the eight eyes in the non-MHE group had LCs. Regarding proximity to the MHE, LCs tended to locate closer than MSLs. Incidental perforating scleral vessels were clearly visible on the tracked SD-OCT scanning line, joining the choroid beneath the border of MHE. Sample cases are illustrated using delicate photographs and explanations.

CONCLUSION

NIA imaging combined with SD-OCT and ICGA can detect and differentiate early the subtle difference between the two types of linear lesions in pathological myopic eyes. Notably, MSLs were not associated with MHEs or LCs in our consecutive series.

The relationship between scleral staphyloma and choroidal thinning in highly myopic eyes: The Beijing Eye Study

Based on the Beijing Eye Study 2011, a detailed ophthalmic examination was performed including spectral-domain optical coherence tomography (SD-OCT) with enhanced depth imaging for measurement of subfoveal choroidal thickness (SFCT) and relative height of posterior scleral staphyloma. OCT images were obtained in 103 highly myopic eyes (≤-6.00 diopters) and 227 normal eyes. The mean SFCT in highly myopic eyes was 110.6 ± 85.2 μm (range, 3 to 395 μm). The SFCT of high myopia without posterior scleral staphyloma(55 eyes) was 157.79 ± 85.18 μm, which was significantly greater than that (54.94 ± 49.96 μm) of high myopia with posterior scleral staphyloma (48 eyes) (P < 0.001). In multivariate analysis, posterior scleral staphyloma was the most important factor of choroidal thinning in high myopia (F = 22.63; P < 0.001), then age (F = 19.14; P < 0.001), axial length (F = 17.37; P < 0.001) and gender (F = 17.31; P < 0.001). The SFCT in highly myopic eyes is very thin and undergoes further thinning with increasing age and axial length (refractive error). Posterior staphyloma formation was a key factor in choroidal thinning in highly myopic eyes and to be a good indicator for risk management of choroidal thinning. Abnormalities of the choroid may play a role in the pathogenesis of myopic degeneration.

Insight into high myopia and the macula

The incidence of myopia is constantly on the rise. Patients of high myopia and pathological myopia are young and can lose vision due to a number of degenerative changes occurring at the macula. With the emergence of new technologies such as swept-source optical coherence tomography (OCT) and OCT angiography, our understanding of macular pathology in myopia has improved significantly. New conditions such as myopic traction maculopathy have been defined. Early, noninvasive detection of myopic choroidal neovascularization and its differentiation from lacquer cracks is possible with a greater degree of certainty. We discuss the impact of these new exciting and promising technologies and management of macular pathology in myopia. Incorporation of OCT in the microscope has also improved macular surgery. New concepts such as fovea-sparing internal limiting membrane peeling have emerged. A review of literature and our experience in managing all these conditions are discussed.

Prevalence of Lens Opacities in Adult Chinese Americans: The Chinese American Eye Study (CHES)

Purpose

We determined the age- and sex-specific prevalence of posterior subcapsular (PSC), nuclear, cortical, and mixed lens opacities in a population-based sample of Chinese-American adults.

Methods

A population-based sample of Chinese-Americans 50 years and older, from 10 census tracts in Monterey Park, CA, USA, underwent a detailed interview and a comprehensive clinical examination that included assessment of different types of lens opacities by the slit-lamp–based Lens Opacities Classification System II (LOCS II). All lens changes (including pseudophakia/aphakia), PSC, nuclear, and/or cortical opacities, were evaluated and graded.

Results

Of the 5782 eligible subjects, 4582 (79.2%) Chinese Americans aged 50 years and older completed a comprehensive eye examination. Of the participants with LOCS II grading (n = 4234/4582, 92%), 3.0% had PSC opacities, 38.1% had nuclear opacities, and 23.4% had cortical opacities. The prevalence of all lens changes was 48.0% for all age groups and was higher by 10-year increasing age groups (P < 0.0001). The prevalence of visual impairment in the better-seeing eye with cortical only, nuclear only, PSC only, and mixed opacities was 3.9%, 5.0%, 14.3%, and 9.4%, respectively. A total of 454 (9.9%) individuals had undergone cataract extraction in at least one eye.

Conclusions

Chinese Americans have a high prevalence of visual impairment associated with lens opacities, and a high prevalence of nuclear opacities. Public health policies and programs designed to improve cataract detection and treatment could help reduce the burden of visual impairment in Chinese Americans.

Epidemiology of Pathologic Myopia in Asia and Worldwide

The myopia epidemic in Asia is evident because the prevalence of high myopia among young adults is higher among Asian (6.8%-21.6%) compared with non-Asian populations (2.0%-2.3%). High myopia is linked to pathologic myopia (PM), which may cause irreversible visual impairment (VI). This review will highlight updates on the prevalence of PM and the associated VI from PM. The prevalence of PM among the middle-aged and elderly (0.9%-3.1%) is higher than the prevalence among children and adolescents (<0.2%). The PM lesions detected among older adults include advanced lesions, such as posterior staphyloma, chorioretinal atrophy, lacquer cracks, and Fuchs spot (in descending frequency of occurrence). A relatively high prevalence of PM (8%) was recently reported among highly myopic young adults. As young individuals grow older, the early grades of PM lesions are likely to progress to advanced grades. Two longitudinal changes that occur frequently in PM include the enlargement of beta peripapillary atrophy and the development of chorioretinal atrophy. The lack of longitudinal changes in PM limits the causal inferences of PM. The prevalence of VI attributed to PM seems to be higher among Asian populations compared with Western and European populations. Pathologic myopia is ranked as a more important cause of blindness and low vision in Asian populations compared with Western and European populations. With the lack of effective treatment strategies and poor prognosis, PM threatens the vision health of populations in Asia and worldwide. To control this future epidemic, the prevention of myopia onset and progression is necessary.

Complications of Pathologic Myopia

Pathologic myopia (PM) is one of the leading causes of visual impairment worldwide. The pathophysiology of PM is not fully understood, but the axial elongation of the eye followed by chorioretinal thinning is suggested as a key mechanism. Pathologic myopia may lead to many complications such as chorioretinal atrophy, foveoschisis, choroidal neovascularization, rhegmatogenous retinal detachment, cataract, and glaucoma. Some complications affect visual acuity significantly, showing poor visual prognosis. This article aims to review the types, pathophysiology, treatment, and visual outcome of the complications of PM.

Soft Contact Lenses with Positive Spherical Aberration for Myopia Control

PURPOSE

To determine whether soft contact lenses with positive spherical aberration (+SA) can slow myopia progression.

METHODS

Eligible subjects (N = 127, primarily Asian) aged 8 to 11 years were randomized to wear either control (spherical design) or test (with +SA) soft daily disposable contact lenses for a minimum of 1 and up to 2 years (treatment phase). Subjects from the initial cohorts (N = 82) were then followed for an additional 1.5 years while wearing a marketed spherical daily disposable contact lens (withdrawal phase). Axial length and spherical equivalent cycloplegic autorefraction (SECAR) were measured at baseline and every 6 months in both phases.

RESULTS

During the first year of treatment, lens type (test vs. control) had a statistically significant impact on axial elongation (p = 0.0409). Eyes wearing test lenses increased in length by 0.11 (65.3%) and 0.14 (38.6%) mm less than eyes wearing control soft lenses at 6 and 12 months, respectively (p < 0.05 at both time points). The principal control of axial elongation occurred during the first 6 months. Spherical equivalent cycloplegic autorefraction change from baseline was significantly less in the test cohort than the control cohort by 0.21D (54.0%) at 6 months (p < 0.05) but not at 12 months (0.14D, p > 0.05). Lens type was not overall a significant factor affecting refractive error change (p = 0.0677). After ceasing treatment, neither the rate of axial elongation nor change in SECAR was significantly different between the initial two cohorts.

CONCLUSIONS

The soft contact lens with +SA slowed axial growth of the eye, although this did not translate into a sustained statistically significant effect on SECAR. The majority of the treatment effect occurred in the initial 6 months of wear. No evidence of rebound effect was observed after ceasing treatment.