Cilioretinal Arteries and Cilioretinal Veins in Eyes with Pathologic Myopia.

We investigated the clinical characteristics of cilioretinal arteries (CAs) and cilioretinal veins (CVs) in eyes with pathologic myopia. Ninety-five eyes with pathologic myopia and CAs were studied. The retrobulbar vessels from which the CAs originated were identified by indocyanine green angiography (ICGA). The results showed that 114 CAs were identified in the 95 eyes. ICGA showed that 60% of the CAs branched directly off the short posterior ciliary arteries (SPCAs) and 40% originated from the Zinn-Haller arterial circle (ZHAC). The SPCA-derived CAs tended to be located superiorly and served a large retinal area whereas the ZHAC-associated CAs tended to be located temporally and served mainly the macular area. In 15% of the 95 eyes, the CVs were observed to run parallel to the CAs. The CVs exited the eye at the same point where the CAs entered the eye. This study showed that CAs in eyes with pathologic myopia can be divided into those that are SPCA-derived and tend to emerge in the superior optic disc sector, and those that are ZHAC-associated and usually emerge temporally. An elongating peripapillary scleral flange in eyes with progressive axial myopia may lead to a change of chorioretinal vascular system.

Development of macular hole and macular retinoschisis in eyes with myopic choroidal neovascularization.

PURPOSE: To determine whether the chorioretinal atrophy (ChRA) adjacent to a choroidal neovascularization (CNV) is related to the development of a macular hole or macular retinoschisis in highly myopic eyes. DESIGN: Observational case series. METHODS: One hundred and eighty-one eyes of 125 patients with high myopia were divided into three groups: group 1 had a myopic CNV surrounded by ChRA larger than 1 disk area (43 eyes), group 2 had a myopic CNV surrounded by a ChRA smaller than 1 disk area (45 eyes), and group 3 did not have CNV (93 eyes). Optical coherence tomography (OCT) was used to evaluate the macular morphologic features, for example, macular holes and macular retinoschisis. RESULTS: A macular hole was detected by OCT in six eyes (14%) in group 1 and in none of the eyes in groups 2 and 3. The hole always existed at the border between an old CNV and the surrounding ChRA. A macular retinoschisis was detected in four eyes (9%) in group 1 and in eight eyes (9%) in group 3. The macular retinoschisis seen in group 1 appeared markedly less column-like than those in group 3. It was somewhat difficult to differentiate a retinal detachment from retinoschisis in the eyes in group 1. CONCLUSIONS: Eyes at the atrophic stage of myopic CNV have a higher risk of developing a macular hole, and we recommend periodic OCT examinations for macular holes or macular retinoschisis, even in asymptomatic, highly myopic eyes, after the CNV has progressed to the atrophic stage.

Morphology and long-term changes of choroidal vascular structure in highly myopic eyes with and without posterior staphyloma.

PURPOSE: To determine whether the choroidal vasculature is altered in highly myopic eyes with or without posterior staphyloma using indocyanine green angiography. In addition, to analyze long-term changes of the choroidal vasculature in patients who were observed for at least 5 years with indocyanine green angiography. DESIGN: Consecutive, retrospective, observational case series. PARTICIPANTS: Three hundred twenty-one eyes of 195 patients with high myopia. METHODS: Indocyanine green angiograms were analyzed, and the effect of posterior staphyloma on the choroidal vasculature was studied. Changes in the indocyanine green-determined choroidal vasculature detected after at least 5 years were analyzed in 57 eyes of 36 patients. MAIN OUTCOME MEASURES: Indocyanine green angiography assessment of the choroidal vasculature. RESULTS: A choroidal flush was detected in all of the control eyes but only 52 (16.2%) of the 321 highly myopic eyes. A displacement of the entry site of the posterior ciliary arteries into the choroid was observed in 76.6% of the eyes with posterior staphyloma and in 25.3% of the eyes without (P<0.001). There were fewer large choroidal veins in the posterior fundus, and in some cases, there was marked variation in the diameter of neighboring large choroidal veins in the highly myopic patients. Of 57 eyes that were followed for >5 years, 9 (15.8%) showed changes in the choroidal vascular structure in the later indocyanine green angiograms. Four of 9 eyes showed dilation or enlargement of posterior routes of choroidal venous outflow, 5 showed narrowing of the large choroidal veins, and 2 had a loss of the large choroidal veins (overlapped). One patient developed choroidal neovascularization after loss of the large choroidal veins. CONCLUSIONS: These findings indicate that the choroidal vasculature can be significantly altered in highly myopic eyes, and this is more prevalent in eyes with posterior staphyloma. Whether these alterations are related to the development of chorioretinal lesions in highly myopic eyes is now being investigated.

Characteristics of peripapillary detachment in pathologic myopia.

OBJECTIVE: To evaluate the prevalence and clinical features of a newly recognized peripapillary lesion specific to high myopia, peripapillary detachment in pathologic myopia (PDPM), in a large series of patients with high myopia. METHODS: Three hundred twenty-four patients (632 eyes) with high myopia were enrolled in this study. We examined the prevalence, range, fluorescein and indocyanine green angiographic findings, and optical coherence tomography findings of PDPM for these patients. Visual field testing (Goldmann kinetic perimetry and the Humphrey 30-2 program) was also performed in the patients with PDPM. RESULTS: Peripapillary detachment in pathologic myopia was identified in 31 of 632 highly myopic eyes (4.9%). The optical coherence tomographic scan across the PDPM lesion revealed a localized detachment of retinal pigment epithelium adjacent to the optic nerve. Although PDPM was always situated adjacent to the inferior edge of the optic disc, in some patients it surrounded almost the entire optic disc. There was a steep excavation of the inferior myopic conus adjacent to the PDPM, and the inferotemporal retinal vein was markedly bent at the transition from the PDPM to the excavated myopic conus. Glaucomatous visual field defects were frequently detected in eyes with PDPM (71.0%). CONCLUSIONS: The findings of this study indicate that PDPM is not uncommon among highly myopic eyes. Although its pathogenesis and pathologic significance require further classification, PDPM might be another indicator of visual field defects in high myopia.

Natural course of macular retinoschisis in highly myopic eyes without macular hole or retinal detachment.

PURPOSE: To investigate the natural course of macular retinoschisis in highly myopic patients. DESIGN: A prospective, observational case series. METHODS: Seven consecutive patients (eight eyes) with macular retinoschisis without macular hole or retinal detachment determined by optical coherence tomography (OCT) were followed at least two years without surgical intervention. The changes in the OCT findings and best-corrected visual acuity (BCVA) were analyzed. RESULTS: During follow-up, two eyes that had vitreoretinal adhesions developed a macular hole, one with and one without retinal detachment (RD), and two eyes without detectable vitreoretinal adhesion developed RD without a macular hole. BCVA in these four eyes was significantly reduced. The remaining four eyes did not develop complications, although the thickness of the macula increased significantly. CONCLUSIONS: These findings suggest that macular retinoschisis might be a progressive condition, and that complications appeared to be related to the presence of vitreoretinal tractions.

Choroidal neovascularization in highly myopic eyes after cataract surgery.

PURPOSE: To determine the incidence and characteristics of choroidal neovascularization (CNV) in patients with high myopia (>or=8 diopters) who underwent cataract surgery in the Department of Ophthalmology, Tokyo Medical and Dental University, or the Ohno Eye Clinic, Tokyo, between September 1991 and March 2000. METHODS: The medical records of 35 patients (48 eyes) who underwent cataract surgery with phacoemulsification and intraocular lens implantation were studied retrospectively. The development of CNV over a 4-year follow-up period, and its characteristics were determined. All of the eyes had received a comprehensive ophthalmological examination, including best-corrected visual acuity measurements, anterior segment biomicroscopy, and a dilated fundus examination by stereoscopic observation. RESULTS: CNV was found in six eyes (12.5%) of six patients. The mean interval between cataract surgery and the development of CNV was 34+/-17 months (range, 12-48 months). The CNV was subfoveal in all cases. The mean logarithm of the minimum angle of resolution (logMAR) after cataract surgery and before the appearance of CNV was 0.23+/-0.24, and 0.93+/-0.41 after the CNV appeared. This decrease was statistically significant (P=0.0008, paired Student t test). Subfoveal CNV developed more frequently in eyes when the fellow eye showed evidence of CNV preoperatively (40.0%) than in eyes when the fellow eye exhibited no evidence of CNV (9.3%). CONCLUSIONS: CNV developed in 12.5% of patients with high myopia after cataract surgery. CNV tended to develop more frequently when the fellow eye had CNV.

Retinal pigment epithelium atrophy secondary to dilated choroidal artery in the macula of a highly myopic patient.

BACKGROUND: Indocyanine green angiography revealed a markedly bent and tortuous choroidal artery in the macula of the left fundus in a highly myopic patient. CASE: The patient's corrected visual acuity was 1.0 in both eyes, and he had no visual symptoms. OBSERVATIONS: Ten years after the initial examination, atrophy of the retinal pigment epithelium (RPE) developed above the dilated choroidal artery. CONCLUSIONS: Optical coherence tomography demonstrated that the RPE was stretched above the markedly dilated choroidal artery. Thus, mechanical stretching of the RPE by an abnormally dilated choroidal artery might underlie the development of RPE atrophy.

Fundus characteristics of high myopia in children.

PURPOSE: To evaluate the fundus characteristics of highly myopic eyes in children. METHODS: We reviewed the medical records of 46 children (1 to 8 years old; mean age, 6.8 years) (80 eyes) with high myopia (4 D or more for children younger than 5 years, 6 D or more for children aged 6-8 years) seen consecutively during a 10-year period at the high-myopia clinic in our hospital. Children of up to 8 years of age at the initial visit were included in the study. RESULTS: Fundus examination revealed posterior staphyloma in only one eye (1.3%) and mild chorioretinal atrophy around the optic disc in 13 eyes (16.3%). There were no patients with choroidal neovascularization or geographic atrophy in the posterior fundus. Myopic peripapillary crescent was observed in 26 eyes (33.8%), but the area of the crescent was relatively small (mean, 0.5 disc area). CONCLUSIONS: The results of the present study showed that myopic fundus changes are uncommon and mild in children. They suggest that aging, in addition to mechanical stretching of the eyeball, might be important for the development of myopic fundus changes.

Prevalence and characteristics of foveal retinal detachment without macular hole in high myopia.

PURPOSE: To report the prevalence of foveal retinal detachment without macular hole in a large number of highly myopic eyes using optical coherence tomography (OCT), and to clarify the demographic characteristics associated with foveal retinal detachment in these eyes. DESIGN: A consecutive, prospective, observational case series. METHODS: In 134 eyes of 78 consecutive patients with high myopia (refractive error of -8 diopters or more), we performed complete ophthalmic examinations and studied cross-sectional images of the macula with OCT. The patients were divided into two groups according to the presence (group 1, n = 78 eyes of 45 patients) or absence (group 2, n = 56 eyes of 33 patients) of posterior staphyloma. Slit-lamp examination with a Goldmann three-mirror lens indicated that none of the eyes had a macular hole. RESULTS: In seven of 78 eyes (9.0%) with posterior staphyloma (group 1), OCT revealed foveal retinal detachment. Two of the seven eyes had foveal retinoschisis. Optical coherence tomography revealed no retinal detachment or retinoschisis in any eye without posterior staphyloma (group 2). Visual acuity of the seven eyes with foveal retinal detachment ranged from 20/40 to 20/200. Two of the seven eyes had visual acuity 20/50 or better. No patients complained of recent, progressive visual impairment. All seven eyes with foveal retinal detachment had severe myopic fundus changes (focal chorioretinal atrophy or bare sclera). CONCLUSIONS: In highly myopic eyes with posterior staphyloma, the prevalence of foveal retinal detachment without macular hole was 9.0%. In eyes with this type of retinal detachment, visual acuity varies and foveal retinal detachment tends to be missed on routine examination. Periodic examination using OCT is recommended for highly myopic eyes with severe myopic degenerative changes and posterior staphyloma.

[The quality of life in patients with pathologic myopia].

PURPOSE: To evaluate the functional status of daily life and the quality of life of pathologic myopia patients. METHODS: A cross-sectional study was conducted using data from pathologic myopia patients(n = 211) and control subjects(n = 144). The influence of the disease on the daily life and the quality of life of patients were evaluated using a self-rating questionnaire. The questionnaire covered the full range of the status of patients' daily life and the quality of life of pathologic myopia patients, including daily tasks depending on visual acuity, social and emotional handicaps, and cognition of disease. RESULTS: The functional status of daily life and the quality of life of patients was reduced compared with control subjects. The influence of pathologic myopia on the patients' daily lives was primarily the result of three major factors: handicap, disability, and support. All three correlated with the quality of life, the degree of handicap having the strongest correlation. CONCLUSION: The functional status of daily life and the quality of life of patients was reduced; this reduction in quality of life was attributed to disability and handicap caused by pathologic myopia.

Trans-Tenon's retrobulbar triamcinolone infusion for myopic choroidal neovascularization.

PURPOSE: To report the effects of trans-Tenon's retrobulbar injection of triamcinolone acetonide for subfoveal and juxtafoveal choroidal neovascularization (CNV) caused by pathological myopia. METHODS: Eleven consecutive patients (11 eyes) with myopic CNV were treated with trans-Tenon's retrobulbar injection of triamcinolone acetonide. Each patient received a single injection. Evaluation included best corrected visual acuity (BCVA) measurements, fluorescein fundus angiography, retinal oedema examined by optical coherence tomography (OCT), and retinal sensitivity using scanning laser ophthalmoscopy (SLO) at the initial examination and at 6 and 12 months after treatment. RESULTS: At 6 months after treatment, BCVA had improved by at least two ETDRS lines in eight eyes, and remained unchanged in three eyes. No eye showed worsening of VA by two or more ETDRS lines. At 12 months, BCVA had improved by at least two ETDRS lines in 10 eyes and remained unchanged in only one eye. The size of the CNV decreased in all patients after treatment. Fluorescein fundus angiography revealed an absence of dye leakage in the late angiographic phase. Optical coherence tomography revealed decreased retinal oedema in all patients and SLO microperimetry revealed an increase in retinal sensitivity in seven eyes, at both 6 and 12 months after treatment. Chorioretinal atrophy developed around the CNV in 10 eyes at 6 months and in all eyes at 12 months after treatment. CONCLUSIONS: Trans-Tenon's retrobulbar injection of triamcinolone acetonide for CNV resulting from pathological myopia appears to be relatively safe and to have a good visual outcome, although a longterm follow-up study in a larger series of patients is necessary.

Characteristics of patients with a favorable natural course of myopic choroidal neovascularization.

OBJECTIVE: To identify the characteristics of patients with myopic choroidal neovascularization (CNV) who had a favorable visual prognosis without treatment. METHODS: We reviewed the medical records of 52 consecutive patients (57 eyes) with myopic CNV who were followed for at least 5 years after the onset of CNV. Clinical characteristics (patient age, CNV size and location, visual acuity at onset, chorioretinal atrophy development around CNV, and degree of myopia) were compared between patients whose visual acuity 5 years after CNV onset was better than 20/40 and those whose visual acuity was worse than 20/200. RESULTS: Among 57 eyes, eight eyes (14.0%; 8 patients) had a final visual acuity better than 20/40. On the other hand, 37 eyes (64.9%; 33 patients) had a final visual acuity worse than 20/200. Statistical analysis revealed that the patients with a good prognosis (final visual acuity better than 20/40) were significantly younger, had significantly smaller CNV, and significantly better initial visual acuity (Mann-Whitney U-test, p<0.05). Juxtafoveal CNV was more frequently observed in patients with a good prognosis than in those with a poor prognosis (Fisher's exact probability test, p<0.05). Only one patient (12.5%) in the good prognosis group developed a very limited area of chorioretinal atrophy around the regressed CNV, while 91.9% of the patients in the poor prognosis group developed chorioretinal atrophy. Refractive status and the axial length measurements did not differ between the two groups. CONCLUSIONS: Some young patients with myopic CNV retain favorable vision over the long term without active treatment. These information might be useful to predict the visual outcome of patients with myopic CNV.

Myopic choroidal neovascularization: a 10-year follow-up.

PURPOSE: To clarify the long-term visual outcome of choroidal neovascularization (CNV) in eyes with high myopia in Asian patients. DESIGN: We reviewed the medical records of 25 consecutive patients (27 eyes) with myopic CNV who were followed up for at least 10 years after the onset of CNV. Visual acuity was examined 10 years after CNV onset. INTERVENTION: Demographic and clinical data were obtained from the patients' medical records. MAIN OUTCOME MEASURES: Visual acuity readings during the 10 years after CNV onset. RESULTS: At the onset of CNV, 19 eyes (70.4%) had a visual acuity better than 20/200, and six eyes (22.2%) had a visual acuity better than 20/40. Three years after the onset of CNV, 15 eyes (55.5%) retained a visual acuity of better than 20/200. At 5 and 10 years after the onset, however, visual acuity dropped to 20/200 or less in 24 eyes (88.9%) and in 26 eyes (96.3%), respectively. The logarithm of the minimum angle of resolution (logMAR) visual acuity was significantly worse at 5 and 10 years after onset as compared with that at CNV onset. Chorioretinal atrophy developed around the regressed CNV in 26 eyes (96.3%) at 5 and 10 years after the onset of CNV. CONCLUSIONS: Long-term visual outcome of myopic CNV is extremely poor. The visual acuity of almost all of the patients dropped to 20/200 or less within 5 to 10 years after the onset of CNV, secondary to the development of chorioretinal atrophy around the regressed CNV. These findings indicate that active treatments should be recommended to prevent long-term visual impairment in Asian patients with myopic CNV.

Optical coherence tomography of choroidal neovascularization in high myopia.

AIM: To investigate morphologic changes in the eye with choroidal neovascularization (CNV) in high myopia using optical coherence tomography (OCT). METHODS: Optical coherence tomography was performed in 35 patients (42 eyes) with myopic CNV. Myopic CNV was divided into active, scar, or atrophic stages based on funduscopic and fluorescein angiographic findings. The characteristics of OCT findings in each stage were identified. RESULTS: In the active stage (11 eyes), OCT clearly displayed a neovascular membrane as a highly reflective dome-like elevation above the retinal pigment epithelium (RPE). No apparent subretinal fluid accumulation around the CNV was identified. In the scar stage (12 eyes), only the surface of the CNV showed high reflectivity, which was markedly attenuated below the surface. In the atrophic stage (19 eyes), the CNV had become totally flat and chorioretinal atrophy around the regressed CNV showed high reflectivity. CONCLUSIONS: Optical coherence tomography demonstrated characteristic features at each stage of myopic CNV. Optical coherence tomography appears to be useful in evaluating the stage and activity of myopic CNV.

Reduction of retinal blood flow in high myopia.

PURPOSE: To investigate changes in retinal vessel diameter and blood velocity in high myopia using laser Doppler velocimetry. METHODS: Thirty-nine subjects (39 eyes) were enrolled in the study. The subjects were divided into three groups according to their refractive status; 15 eyes (15 patients) with emmetropia (within +/-3.0 diopters), 14 eyes (14 patients) with mild myopia (between -3.0 and -8.0 diopters), and 10 eyes (10 patients) with high myopia (>-8.0 diopters). Patient age was matched between groups. Blood velocity and vessel diameter of the upper or lower temporal retinal artery were measured using laser Doppler velocimetry with an eye-tracking system, and measurements were compared between groups. RESULTS: The average retinal blood flow and vessel diameter in highly myopic eyes were significantly decreased compared with emmetropic eyes or mild myopic eyes (Mann-Whitney U test, p<0.05). Also, there was significant difference regarding retinal blood flow and vessel diameter between eyes with mild myopia and the other groups. In addition, there was no significant difference in blood velocity between the three groups. CONCLUSIONS: Retinal blood flow was decreased in high myopia, mainly due to the narrowing of the retinal vessel diameter. Impaired retinal blood flow might have a role in the development of chorioretinal atrophy in high myopia.

Factors associated with the development of chorioretinal atrophy around choroidal neovascularization in pathologic myopia.

PURPOSE: To examine the influencing factors on the development of chorioretinal atrophy, which is the main cause of long-term visual decrease in myopic choroidal neovascularization (CNV), in a large series of highly myopic patients. METHODS: Sixty-five patients (81 eyes) with myopic CNV were studied retrospectively. The influence of the patient's age, refractive error, axial length, visual acuity at onset of CNV, size of CNV, and grade of myopic retinopathy on the extent of chorioretinal atrophy more than 3 years after CNV onset was investigated by means of multiple linear regression analysis. RESULTS: Seventy-seven of 81 eyes (95.1%) developed chorioretinal atrophy around myopic CNV during the follow-up period. Multiple linear regression revealed that age was the most influencing factor for the development of chorioretinal atrophy in all the subjects. When we divided the subjects into two groups according to their age, however, CNV size was the only factor to influence the development of chorioretinal atrophy in the patients younger than 40 years, whereas age was still the only influencing factor in those older than 40 years. CONCLUSIONS: The factors influencing the development of chorioretinal atrophy differ according to patient age. Local factors, such as CNV size, determine the tendency to develop chorioretinal atrophy in young patients. Systemic factors, such as patient age, play a greater part in older subjects.

Long-term visual prognosis of choroidal neovascularization in high myopia: a comparison between age groups.

OBJECTIVE: To analyze visual outcome in highly myopic patients of different age groups with choroidal neovascularization (CNV). DESIGN: Retrospective observational case series. PARTICIPANTS: We reviewed the medical records of 63 consecutive patients (73 eyes) with myopic CNV. The patient population was divided into two groups according to age at onset of CNV (< or =40 and >40 years old). INTERVENTION: Demographic and clinical data were obtained from the patients' medical records. MAIN OUTCOME MEASURES: Visual acuity at least 3 years after CNV diagnosis. RESULTS: Group 1 (< or =40 years old) consisted of 22 patients (26 eyes), and group 2 (>40 years old) consisted of 41 patients (47 eyes). Throughout the follow-up period, group 1 retained better visual acuity than group 2. Almost half the patients in group 1 retained a final visual acuity better than 20/40. No significant change occurred in the logarithm of the minimum angle of resolution (logMAR) in group 1 during follow-up. Group 2 had worse visual acuity at the initial evaluation than did group 1, and a statistically significant worsening of logMAR was found during the follow-up period. More than half of the patients in group 2 had a final visual acuity less than 20/200. In addition, group 2 had a larger area of CNV, and chorioretinal atrophy was more frequently seen after the regression of CNV than in group 1. CONCLUSIONS: The visual prognosis of myopic CNV is influenced by age at onset. The results of this study indicate that patient age at the time of onset of myopic CNV should be considered when determining the therapeutic course.