110 Jeganathan et al.

Myopic Maculopathy

Several population-based studies have not found an association between myopia and AMD.72,73 In contrast, the Beijing Eye Study showed that highly myopic eyes had a significant lower prevalence of early and late AMD, compared to non-highly myopic eyes.74 Macular choroidal neovascularisation (CNV) is the most common vision-threatening complication of high myopia,24 especially in persons younger than 50 years.75,76 The impact of myopic degeneration on visual impairment is important, because it is often bilateral, irreversible, and affects individuals during their productive years.77

Several studies report a prevalence of myopic degeneration at about 1% in the general population in Asia.78 Clinical and histopathological studies have documented CNV in 5% to 10% of eyes with axial length of over 26.5mm.33 CNV has been reported to develop in 12.5% of patients with high myopia after cataract surgery.79 Among myopic patients with preexisting CNV, more than 30% develop CNV in the fellow eye within eight years.31 Myopic degeneration may occur independently of the scleral conus, or it may be caused by enlargement of the temporal conus, involving the macular region. In highly myopic eyes, the Forster-Fuchs’ spot at the macula forms due to the proliferation of pigment epithelium and deposition of blood pigment following choroidal haemorrhage from the neovascular tissue.80 The Forster–Fuchs’ spot has been found in 3.2% to 20% of patients identified with pathological myopia, predominantly in middle age.28,81 Myopic CNV is considered to have a limited course, in contrast to CNV secondary to AMD.31 Some studies report a favorable visual acuity outcome of myopic CNV,31,82 while others report a poorer prognosis.83–85 Imaging modalities including OCT, angiography, and fundus autofluorescence have provided further insights into the in vivo pathology of myopic CNV.86 Therapeutic interventions to date include laser photocoagulation and pharmacologic agents, such as steroids and anti-angiogenic drugs.

Myopic Retinopathy

Myopic retinopathy refers to a cluster of signs that indicate degeneration of the chorioretinal tissues associated with the excessive axial elongation of the myopic eye, leading to mechanical stretching and thinning of the choroid and retinal pigment epithelium with concomitant vascular and

111 Ocular Morbidity of Pathological Myopia

degenerative changes.28,87 Posterior pole changes include posterior staphyloma, lacquer cracks, Fuchs’ spot, and chorioretinal atrophy.29,88 Peripheral retinal features of myopic retinopathy include lattice, paving stone, white- without-pressure, and pigmentary degenerations, as well as retinal tears.87,88 In BMES, progression of myopic retinopathy was observed in 17.4% of eyes after five years.29 Posterior pole staphyloma has been reported to be the most common type of staphyloma.89 Lacquer cracks or ruptures in the retinal pigment epithelium-Bruch’s membrane-choriocapillaris complex have been reported in patients with high myopia.90 The prevalence of lacquer cracks has ranged from 0.2% to 9.2% in highly myopic populations,28,81 and may characterize an unfavorable prognosis in patients with pathologic myopia.91 In studies by Pierro et al. and Gozum et al., it was found that longer axial length was associated with increased prevalence of lattice degeneration, pavingstone degeneration, and white-without- pressure.87,92 Chorioretinal atrophy occurs in the late stage of myopic degeneration.16 Macular hole formation is an important complication of highly myopic eyes, and it is frequently complicated by macular hole retinal detachment.93–95 Studies by Azzolini and Benhamou correlated the biomicroscopic signs of early macular holes (e.g. microcystic appearance, macular striae) with the presence of foveal retinoschisis, as well as prefoveal tractional membranes on OCT images.96,97

Retinal Detachment

Retinal breaks and retinal detachment (RD) occur more frequently in eyes with increased axial length as a result of lattice degeneration, increased frequency of posterior vitreous detachment, or macular hole formation.98 Round and multiple retinal breaks characterize myopic retinal detachment. The yearly incidence of retinal detachments has been estimated as 0.015% in patients with less than 4.75 D myopia, increases to 0.07% in patients with ≥5 D myopia and 3.2% in patients’ ≥6 D myopia.99,100 Posterior vitreous detachment tends to occur at an earlier age, in high myopes.101 The prevalence of posterior vitreous detachment was 12.5% in

a case series of patients with high myopia, and 60.7% in patients with axial length >30mm.101 Up to 6.3% of highly myopic eyes are reported to

develop asymptomatic macular holes, confirmed by ocular coherence tomography.102,103 Macular holes in patients with pathological myopia are caused by traction effects of firm vitreoretinal adhesions.104 Consequently,

113 Ocular Morbidity of Pathological Myopia

associated pathology is rising in several countries. Thus, it is important to prevent a possible rise in blindness due to the myopia epidemic. Furthermore, refractive surgical procedures such as laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) have achieved emmetropia in high myopes, but do not eliminate the myriad of posterior segment complications that are potentially incapacitating. Given that the ocular morbidity of myopia may constitute an important clinical, public health, and economic problem, an integrated, pragmatic public health approach with community-based eye screening and research programs, as well as correcting myopia and retarding myopia progression are important. The early detection and management of degenerative eye diseases is central in the care of myopic adults in the prevention of visual impairment and blindness. The prevalence of pathologic myopia is expected to increase with ageing populations and with time due to the cohort effect. Myopic degeneration, macular holes, and retinal detachment are lesions that are potentially blinding. If the risks of pathologic myopia are proportional to the severity of myopia, measures to prevent the early onset and rapid progression of myopia in childhood will eliminate or reduce pathologic myopia later in life.

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