Positive and Negative Associations of Myopia with Ocular Diseases in Population-Based Studies.

PURPOSE: Prevalence of myopia and vision impairment due to myopic macular degeneration and myopia-related optic neuropathies have markedly increased worldwide. We evaluated whether myopia is associated with other ocular disorders. DESIGN: Population-based studies conducted in Russia, China, and India. PARTICIPANTS: The Russian Ural Eye and Medical Study (UEMS) and the Beijing Eye Study (BES) included 5899 individuals and 4439 individuals (all aged 40+ years), respectively, and the Central India Eye and Medical Study (CIEMS) consisted of 4711 individuals aged 30+ years. The studies were conducted in rural and urban regions in Bashkortostan/Russia, Nagpur/India, and Beijing/China. METHODS: The participants underwent a series of ophthalmological and general medical examinations. MAIN OUTCOME MEASURES: Axial length as a surrogate for myopia and prevalence of diabetic retinopathy (DR), age-related macular degeneration (AMD), angle-closure glaucoma (ACG), and open-angle glaucoma (OAG). RESULTS: In the UEMS, DR prevalence (odds ratio [OR], 0.73), AMD prevalence (OR, 0.85), and ACG prevalence (OR, 0.72) decreased, and OAG prevalence (OR, 1.65) increased with longer axial length in multivariable analyses. In the CIEMS, lower AMD prevalence (OR, 0.81) and lower ACG prevalence (OR, 0.55), and higher OAG prevalence (OR, 1.45) were associated with longer axial length. Diabetic retinopathy prevalence (0.33%) was too low for statistical analysis in the CIEMS. In the BES, prevalence (OR, 0.64) and 10-year incidence of DR (OR, 0.48) and prevalence (OR, 0.83) and 5-year incidence of AMD (OR, 0.996) decreased, and prevalence (OR, 1.35) and 10-year incidence of OAG (OR, 1.40) increased with longer axial length. In all 3 studies, the association between higher OAG prevalence and longer axial length was nonlinear with a slight increase for the moderate myopia range and a steep increase in the highly myopic range. CONCLUSIONS: Myopia is associated with a lower prevalence of DR, AMD, and ACG and a lower incidence of DR and AMD, whereas high myopia more than moderate myopia is associated with a higher prevalence and incidence of OAG. Future studies may assess whether in myopia (in particular, in moderate myopia), the myopia-related advantages, that is, lower prevalence of DR, AMD, and ACG, may outweigh the increased risks for OAG and other myopia-related disorders. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Is Kidney Function Associated with Age-Related Macular Degeneration?: Findings from the Asian Eye Epidemiology Consortium.

PURPOSE: Chronic kidney disease (CKD) may elevate susceptibility to age-related macular degeneration (AMD) because of shared risk factors, pathogenic mechanisms, and genetic polymorphisms. Given the inconclusive findings in prior studies, we investigated this association using extensive datasets in the Asian Eye Epidemiology Consortium. DESIGN: Cross-sectional study. PARTICIPANTS: Fifty-one thousand two hundred fifty-three participants from 10 distinct population-based Asian studies. METHODS: Age-related macular degeneration was defined using the Wisconsin Age-Related Maculopathy Grading System, the International Age-Related Maculopathy Epidemiological Study Group Classification, or the Beckman Clinical Classification. Chronic kidney disease was defined as estimated glomerular filtration rate (eGFR) of less than 60 ml/min per 1.73 m2. A pooled analysis using individual-level participant data was performed to examine the associations between CKD and eGFR with AMD (early and late), adjusting for age, sex, hypertension, diabetes, body mass index, smoking status, total cholesterol, and study groups. MAIN OUTCOME MEASURES: Odds ratio (OR) of early and late AMD. RESULTS: Among 51 253 participants (mean age, 54.1 ± 14.5 years), 5079 had CKD (9.9%). The prevalence of early AMD was 9.0%, and that of late AMD was 0.71%. After adjusting for confounders, individuals with CKD were associated with higher odds of late AMD (OR, 1.46; 95% confidence interval [CI], 1.11-1.93; P = 0.008). Similarly, poorer kidney function (per 10-unit eGFR decrease) was associated with late AMD (OR, 1.12; 95% CI, 1.05-1.19; P = 0.001). Nevertheless, CKD and eGFR were not associated significantly with early AMD (all P ≥ 0.149). CONCLUSIONS: Pooled analysis from 10 distinct Asian population-based studies revealed that CKD and compromised kidney function are associated significantly with late AMD. This finding further underscores the importance of ocular examinations in patients with CKD. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Drusen in the macula and parapapillary region.

PURPOSE: To examine histological characteristics and differences between drusen beneath the retinal pigment epithelium (small hard drusen) located in the macula and located in the parapapillary region. METHODS: We histomorphometrically examined human eyes enucleated due to uveal melanomas or secondary angle-closure glaucoma. RESULTS: The study included 106 eyes (age, 62.6 ± 15.2 years) with macular drusen (n = 7 globes) or parapapillary drusen (n = 29 eyes) and 70 eyes without drusen. In all drusen, periodic-acid-Schiff-positive material was located between the RPE basal membrane and the inner collagenous layer of Bruch's membrane (BM). Macular drusen as compared with parapapillary drusen had lower height (15.2 ± 10.1 µm versus 34.3 ± 19.8 µm; P = 0.003), while both groups did not differ significantly in basal drusen width (74.0 ± 36.3 µm versus 108.7 ± 101.0 µm; P = 0.95). Eyes with macular drusen and eyes without drusen did not differ significantly in BM thickness (2.74 ± 0.44 µm versus 2.55 ± 0.88 µm; P = 0.57) or in RPE cell density (35.4 ± 10.4 cells/480 µm versus 32.8 ± 7.5 cells/480 µm; P = 0.53), neither in the drusen region nor in the drusen vicinity, while BM thickness (4.60 ± 1.490 µm; P < 0.001) and RPE cell density (56.9 ± 26.8 cells/480 µm; P = 0.005) were higher at the parapapillary drusen. Eyes with macular drusen, eyes with parapapillary drusen, and eyes without drusen did not differ significantly in choriocapillaris density (all P > 0.10) and thickness (all P > 0.35). Limitations of the study, among others, were a small number and size of drusen examined, diseases leading to enucleation, lack of serial sections, limited resolution of light microscopy, and enucleation-related and histological preparation-associated artefacts. CONCLUSIONS: The findings of this study, also taking into account its methodological limitations, suggest that macular drusen and parapapillary drusen shared the morphological feature of periodic-acid-Schiff-positive material between the RPE basal membrane and BM and that they did not vary significantly in choriocapillaris thickness and density. RPE cell density and BM thickness were higher in parapapillary drusen than in macular drusen.

Myopia and Other Refractive Error and Their Relationships to Glaucoma Screening.

PRCIS: A large disk, a large parapapillary delta zone and a long axial length may be used as screening criteria to detect glaucomatous optic neuropathy in highly myopic eyes. PURPOSE: To describe aspects for screening of glaucomatous optic neuropathy in dependence of refractive error, under special consideration of high myopia. METHODS/RESULTS: Studies on the anatomy of the myopic optic nerve head and results of investigations on the relationship between glaucomatous optic neuropathy and axial myopia were included. CONCLUSIONS: In the range from hyperopia to moderate myopia, refractive error is not a strong glaucoma risk factor and may not be included in glaucoma screening strategies. Care should be taken, that in moderate myopia, a shift of Bruch´s membrane opening usually into the temporal direction leads to parapapillary gamma zone and a corresponding shortening of the horizontal disk diameter. In these moderately myopic eyes, a secondarily small optic disk with a correspondingly small optic cup should not lead to an overlooking of intrapapillary glaucomatous changes. Prevalence of glaucomatous or glaucoma-like optic nerve atrophy (GOA) steeply increases with longer axial length in highly myopic eyes (cutoff approximately -8 diopters/axial length 26.5 mm), with prevalences higher than 50% in extremely high myopia. Besides longer axial length, morphological parameters associated with GOA in highly myopic eyes are a secondarily enlarged disk and large parapapillary delta zone. Both parameters, together with long axial length, may be used as screening criteria in high myopia for GOA. The latter is characterized by an abnormal neuroretinal rim shape, that is, vessel kinking close to the intrapapillary disk border. Factors associated with nonglaucomatous optic neuropathy are larger gamma zone and longer axial length, potentially due to an axial elongation-related retinal nerve fiber stretching.

Bruch's membrane and Brücke's muscle in the pars plana region.

PURPOSE: To examine Bruch's membrane (BM) in association with the longitudinal part of the ciliary muscle (LPCM) in the pars plana region. METHODS: Using light microscopy, we histomorphometrically assessed BM and the LPCM in the pars plana region. RESULTS: The histomorphometric study included 51 eyes (51 patients; mean age: 60.8 ± 15.0 years; axial length: 26.0 ± 3.3 mm; range: 21.0-36.0 mm). The LPCM (total length: 4.60 ± 1.10 mm) ended 1.15 ± 0.56 mm anterior to the ora serrata. Within the pars plana region, the LPCM (length: 2.58 ± 0.98 mm) had direct contact with BM for 1.95 ± 0.99 mm (71.1 ± 18.4% of the BM undersurface), while a capillary layer was interposed between the BM and the LPCM for 0.70 ± 0.40 mm (29.0 ± 18.4%). In the pars plana region free of LPCM close to the ora serrata, the percentage of BM covered by the capillary layer was higher than in the pars plana region containing the LPCM (63.0 ± 42.1% vs. 29.0 ± 18.4%; p < 0.001). At the LPCM end, BM was in direct contact with a collagenous tissue from the LPCM and was focally thickened as compared to BM with an underlying capillary layer (9.5 ± 5.3 µm vs. 4.3 ± 1.2 µm; p < 0.001). CONCLUSIONS: The direct contact of BM with the LPCM in the pars plana in association with focal BM thickening at the LPCM end suggests an insertion of LPCM on the BM. Taking into account the biomechanical strength of BM, it may imply a functional unit of the LPCM with BM in the process of accommodation with a secondary movement of the posterior BM and tertiary thickening of the subfoveal choroidal space.

Prevalence of Myopic Maculopathy Among the Very Old: The Ural Very Old Study.

Purpose: To assess the prevalence of myopic macular degeneration (MMD) in very old individuals. Methods: The population-based Ural Very Old Study (UVOS) included 1526 (81.1%) of 1882 eligible inhabitants aged ≥85 years. Assessable fundus images were available for 930 (60.9%) individuals (mean age, 88.6 ± 2.7 years). MMD was defined by macular patchy atrophies (i.e., MMD stage 3 and 4 as defined by the Pathologic Myopia Study Group). Results: MMD prevalence was 21 of 930 (2.3%; 95% CI, 1.3-3.3), with 10 individuals (1.1%; 95% CI, 0.4-1.7) having MMD stage 3 and 11 participants (1.2%; 95% CI, 0.5-1.9) MMD stage 4 disease. Within MMD stage 3 and 4, prevalence of binocular moderate to severe vision impairment was 4 of 10 (40%; 95% CI, 31-77) and 7 of 11 (64%; 95% CI, 30-98), respectively, and the prevalence of binocular blindness was 2 of 10 (20%; 95% CI, 0-50) and 3 of 11 (27%; 95% CI, 0-59), respectively. In minor myopia (axial length, 24.0 to <24.5 mm), moderate myopia (axial length, 24.5 to <26.5 mm), and high myopia (axial length, ≥26.5 mm), MMD prevalence in the right eyes was 0 of 46 eyes (0%), 3 of 40 eyes (8%; 95% CI, 0-16), and 7 of 9 (78%; 95% CI, 44-100), respectively; MMD prevalence in the left eyes was 1 in 48 eyes (2%; 95% CI, 0-6), 4 of 36 eyes (11%; 95% CI, 0-22), and 3 of 4 eyes (75%; 95% CI, 0-100), respectively. In multivariable analysis, a higher MMD prevalence (odds ratio, 8.89; 95% CI, 3.43-23.0; P < 0.001) and higher MMD stage (beta, 0.45; B, 19; 95% CI, 0.16-0.22; P < 0.001) were correlated with longer axial length but not with any other ocular or systemic parameter. Conclusions: MMD prevalence (stages 3 and 4) in very old individuals increased 8.89-fold for each mm axial length increase, with a prevalence of ≥75% in highly myopic eyes. In old age, highly myopic individuals have a high risk of eventually developing MMD with marked vision impairment.

Wide-Field Optical Coherence Tomography Imaging Improves Rate of Change Detection in Progressing Glaucomatous Eyes Compared With Standard-Field Imaging.

Purpose: To compare rates of retinal nerve fiber layer change over time in healthy, eyes with nonprogressing glaucoma and eyes with progressing glaucoma using single wide-field (SWF) and optic nerve head (ONH) cube scan optical coherence tomography (OCT) images. Methods: Forty-five eyes of 25 healthy individuals and 263 eyes of 161 glaucoma patients from the Diagnostic Innovations in Glaucoma Study were included. All eyes underwent 24-2 visual field testing and OCT (Spectralis SD-OCT) ONH and macular imaging. SWF images (up to 43° × 28°) were created by stitching together ONH cube scans centered on the optic disc and macular cube scans centered on the fovea. Visual field progression was defined as guided progression analysis likely progression and/or a significant (P < 0.01) mean deviation slope of less than -1.0 dB/year. Mixed effects models were used to compare rates of change. Highly myopic eyes were included. Results: Thirty glaucomatous eyes were classified as progressing. In eyes with glaucoma, mean global rate of change was -1.22 µm/year (P < 0.001) using SWF images and -0.83 µm/year (P = 0.003) using ONH cube scans. Rate of change was significantly greater in eyes with progressing glaucoma compared with eyes with nonprogressing glaucoma (-1.51 µm/year vs. -1.24 µm/year; P = 0.002) using SWF images and was similar using ONH cube scans (P = 0.27). Conclusions: In this cohort that includes eyes with and without high axial myopia, the mean rate of retinal nerve fiber layer thinning measured using SWF images was faster in eyes with progressing glaucoma than in eyes with nonprogressing glaucoma. Wide-field OCT images including the ONH and macula can be effective for monitoring glaucomatous progression in patients with and without high myopia.

Lamina Cribrosa Configurations in Highly Myopic and Non-Highly Myopic Eyes: The Beijing Eye Study.

Purpose: The purpose of this study was to examine characteristics of lamina cribrosa (LC) configuration in highly myopic (HM) eyes. Methods: Participants from the Beijing Eye Study 2011, free of optic nerve or retinal diseases, were randomly selected to examine LC depth (LCD) and LC tilt (LCT) using three-dimensional optical coherent tomography images of the optic nerve head (ONH). LCD and LCT were measured as the distance and angle between the LC plane with two reference planes, including the Bruch's membrane opening (BMO) plane and the peripapillary sclera (PPS) plane, respectively. Each parameter was measured in both horizontal and vertical B-scans. Results: The study included 685 individuals (685 eyes) aged 59.6 ± 7.7 years, including 72 HM eyes and 613 non-HM eyes. LCD measurements showed no significant differences between HM eyes and non-HM eyes in both horizontal (LCD-BMO = 421.83 ± 107.86 µm for HM eyes vs. 447.24 ± 104.94 µm for non-HM eyes, P = 0.18; and LCD-PPS = 406.39 ± 127.69 µm vs. 394.00 ± 101.64 µm, P = 1.00) and vertical directions (LCD-BMO = 435.78 ± 101.29 µm vs. 450.97 ± 106.54 µm, P = 0.70; and LCD-PPS = 401.62 ± 109.9 µm vs. 379.85 ± 110.35 µm, P = 0.35). However, the LCT was significantly more negative (tilted) in HM eyes than in non-HM eyes horizontally (LCT-BMO = -4.38 ± 5.94 degrees vs. -0.04 ± 5.86 degrees, P < 0.001; and LCT-PPS = -3.16 ± 5.23 degrees vs. -0.94 ± 4.71 degrees, P = 0.003), but not vertically (P = 1.00). Conclusions: Although LCD did not differ significantly between HM and non-HM eyes, LCT was more negative in HM eyes, suggesting that the temporal or inferior side of the LC was closer to the reference plane. These findings provide insights into morphological and structural changes in the LC and ONH between HM and non-HM eyes.

Atrial fibrillation and flutter and ocular diseases. The Ural eye and medical study and the Ural very old study.

PURPOSE: To assess associations between atrial fibrillation/atrial flutter (AF) and ocular parameters and diseases. METHODS: The population-based Ural Eye and Medical Study (UEMS) and the Ural Very Old Study (UVOS) included 4894 individuals (age: 40+ years) and 835 individuals (age: 85+ years), respectively. RESULTS: In the UEMS, AF prevalence (80/4894; 1.6%; 95% CI: 1.3, 2.0) increased from 1/1029 (0.1%) in the age group of 40 to <50 years to 29/619 (4.7%) and 12/159 (7.5%) in the age groups of 70 to <80 years and 80+ years, respectively. Higher AF prevalence correlated with older age (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), urban region of habitation (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), higher prevalence of cardiovascular disease/stroke (OR: 2.50; 95% CI: 1.32, 4.72; p < 0.001) and lower prevalence of neck pain (OR: 0.35; 95% CI: 0.14, 0.85; p = 0.02), higher serum concentration of bilirubin (OR: 1.03; 95% CI: 1.02, 1.05; p < 0.001) and lower prothrombin index (OR: 0.96; 95% CI: 0.93, 0.99; p = 0.003), higher stage of arterial hypertension (OR: 1.52; 95% CI: 1.01, 2.28; p = 0.04) and higher ankle-brachial index (OR: 22.1; 95% CI: 4.45, 1.10; p < 0.001). In that model, AF prevalence was not associated with ocular parameters such as intraocular pressure (p = 0.52), retinal nerve fibre layer thickness (p = 0.70), refractive error (p = 0.13), axial length (p = 0.14), nuclear cataract degree (p = 0.50) and prevalence (p = 0.40), cortical cataract degree (p = 0.43) and presence (p = 0.17), lens pseudoexfoliation (p = 0.58), status after cataract surgery (p = 0.38), age-related macular degeneration prevalence (p = 0.63), open-angle glaucoma presence (p = 0.90) and stage (p = 0.55), angle-closure glaucoma prevalence (p = 0.99) and stage (p = 0.99), diabetic retinopathy prevalence presence (p = 0.37) and stage (p = 0.32), and myopic macular degeneration (p = 0.98). In the UVOS, similar results were obtained. CONCLUSIONS: In these multi-ethnic populations from Russia, AF prevalence was not associated with any major ocular disease and may not play a major role in the pathogenesis of these disorders.

Diagnostic Accuracy of Optic Nerve Head and Macula OCT Parameters for Detecting Glaucoma in Eyes With and Without High Axial Myopia.

PURPOSE: To characterize structural differences and assess the diagnostic accuracy of optic nerve head (ONH) and macula optical coherence tomography (OCT) parameters to detect glaucoma in eyes with and without high axial myopia. DESIGN: Cross-sectional study. METHODS: Three hundred sixty-eight glaucoma and 411 healthy eyes with no axial myopia, 393 glaucoma and 271 healthy eyes with mild axial myopia and 124 glaucoma and 85 healthy eyes with high axial myopia were included. Global and sectoral peripapillary retinal nerve fiber layer thickness (pRNFLT), Bruch's membrane opening minimum rim width (BMO-MRW), ganglion cell inner plexiform layer thickness (GCIPLT), and macula RNFLT (mRNFLT) were compared and the diagnostic accuracy for glaucoma detection was evaluated using the adjusted area under the receiver operating characteristic curve (AUC). RESULTS: Diagnostic accuracy for ONH and macula parameters to detect glaucoma was generally high and differed by myopia group. For ONH parameters the diagnostic accuracy was highest for global (AUC = 0.95) and inferotemporal (AUC = 0.91) pRNFLT for high myopes and global BMO-MRW for nonmyopes (AUC = 1.0) and mild myopes (AUC = 0.97). For macula parameters, the diagnostic accuracy was higher in high myopes with 6 of the 11 GCIPLT global/sectors having adjusted AUCs > 0.90 compared to nonhigh myopes with no AUCs > 0.90. In all myopia groups, mRNFLT had lower AUCs than GCIPLT. CONCLUSIONS: The diagnostic accuracy for pRNFL and GCIPL was high for high axial myopic eyes and shows promise for glaucoma detection in high myopes. Further analysis is needed to determine whether the high diagnostic accuracy can be confirmed in other populations.

Prevalence and Associated Factors of Cataract, Cataract Surgery and Postoperative Outcome in an Old Population in Russia: The Ural Very Old Study.

Purpose: To assess prevalence of cataract and cataract surgery in a very old population in Russia. Design: Population-based study. Participants: The Ural Very Old Study included 1526 (81.1%) participants of 1882 eligible individuals aged >85 years. Methods: Series of ophthalmological examinations. Main Outcome Measures: Prevalence of cataract and cataract surgery. Results: The study included 1163 (76.3%) individuals with lens information. Cataract surgery had been performed in 469 right eyes (41.0%; 95% confidence interval [CI]: 38.1-43.9) (92.1% with posterior chamber intraocular lens [IOL]; 4.7% with multifocal IOL) and 479 left eyes (41.6%; 95% CI: 38.7-44.4) (92.7% with posterior chamber IOL; 4.2% with multifocal IOL). Cataract surgery had been performed in at least one eye for 610 (52.5%) individuals. Higher prevalence of previous cataract surgery correlated (multivariable analysis) with lower IOP (OR: 0.92; 95% CI: 0.88-0.95), glaucomatous optic nerve damage stage (OR: 1.20; 95% CI: 1.05-1.36), and better visual acuity (OR: 0.67; 95% CI: 0.51-0.89). Postoperative best corrected visual acuity was reduced to moderate-to-severe vision impairment (MSVI) in 202 eyes (44.6%; 95% CI: 40.0-49.2) and to blindness in 53 eyes (11.7%; 95% CI: 8.7-14.7). Causes of postoperative MSVI were age-related macular degeneration (AMD) (34.2%), glaucoma (13.9%), and secondary cataract (5.4%). Causes for blindness were AMD (24.5%), glaucoma (18.9%), corneal opacifications (15.8%) and myopic macular degeneration (11.3%). Yttrium Aluminum Garnet-laser capsulotomy had been performed in 6 (1.3%) of 469 right eyes and 12 (2.5%) of 479 left eyes. Prevalence of nuclear cataract and cortical cataract was 604/671 (90.0% in phakic eyes; 51.9% in the whole study population) and 97.9% eyes (48.4% in total study population). Cataract caused bilateral MSVI and blindness in 28.2% (95% CI: 25.6-30) and 2.9% (95% CI: 1.9-3.9), respectively, of all study participants. Conclusions: Despite a relatively high prevalence of cataract surgery, this multiethnic cohort >85 years of aged from Russia showed a high prevalence of cataract-related MSVI and blindness. Main causes for postoperative MSVI (prevalence: 44.6%) and blindness (prevalence: 11.7%) were AMD, glaucoma, corneal opacifications, and myopic macular degeneration. Almost all individuals aged 85+ years need cataract surgery, despite limited chance of postoperative good vision. Financial Disclosures: The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Intraocular pressure and its determinants in a very old population. The ural very old study.

Purpose: To explore intraocular pressure (IOP) and its associated parameters in an aged population. Methods: The epidemiologic Ural Very Old Study (UVOS) conducted in Bashkortostan/Russia included 1526 participants with an age of ≥85 years. Besides a whole series of ocular and systemic examinations, IOP was determined applying non-contact tonometry. Body mass index, diastolic blood pressure and age were the factors used to estimate the cerebrospinal fluid pressure (CSFP). Results: The study consisted of 904 participants (age: 88.6 ± 2.7 years) with available IOP readings and without anti-glaucomatous therapy. Mean IOP was 14.5 ± 5.1 mmHg (median: 14 mm Hg; Q1:11; Q3:16; 95%CI:8,25) and 14.8 ± 4.6 mmHg (median: 14 mm Hg; Q1:12; Q3:17; 95%CI:8,28) in the right and left eyes, respectively. Higher IOP correlated (multivariable analysis; correlation coefficient r2:0.32) with female sex (P < 0.001), more sedentary lifestyle (P = 0.006), higher estimated CSFP (P < 0.001), higher total protein serum concentration (P < 0.001), stronger hand grip force (P = 0.01), thicker central cornea (P < 0.001), longer axial length (P = 0.01), absence of previous cataract surgery (P = 0.001), higher degree of pseudoexfoliation (P = 0.02, and thinner peripapillary retinal nerve fiber layer thickness (P = 0.004). Using this that model, IOP reading enlarged by 0.22 mmHg (95% CI: 0.09, 0.35) for each increase in estimated CSFP by 1 mm Hg, by 0.03 mm Hg (95% CI: 0.02,0.05) for each thickening in central corneal thickness by 1 µm, by 0.56 mm Hg (95%CI: 0.13,1.00) for each axial elongation by 1 mm, and by 0.40 mmHg (95% CI: 0.06,0.74) for each increase in the degree of pseudoexfoliation, and it decreased by 0.40 mmHg (95% CI: 0.06,0.74) by cataract surgery. Conclusions: In this study population aged 85+years, IOP readings showed similar relationships as in younger study populations, including positive associations with higher estimated CSFP and longer axial length and a negative association with cataract surgery.

Myopic Macular Atrophy in the Two-Continent Population-Based Study.

Purpose: To examine the prevalence of Bruch's membrane defects (BMDs) and subretinal proliferations (SRPs) in highly myopic eyes with myopic macular atrophy (myopic macular degeneration [MMD] stage 4) and myopic patchy atrophies (MMD stage 3) in three ethnically different cohorts recruited in a population-based manner. Methods: The Ural Eye and Medical Study (UEMS) and Beijing Eye Study (BES) included individuals aged 40+ years, and the Ural Very Old Study (UVOS) examined individuals aged 85+ years. Main outcome measures were the prevalence of BMDs and SRPs. Results: Among 5794 UEMS participants, 19 eyes had MMD stage 4, with 17 (89%) eyes showing a foveal BMD; two eyes could not fully be explored. All 19 eyes showed localized SRPs. Among 21 eyes with MMD stage 3, BMD and SRP prevalence was 9 of 21 (44%) and 7 of 21 (33%), respectively. Among 930 UVOS participants, 17 eyes had MMD stage 4, with 16 (94%) eyes showing foveal BMDs and SRPs; one eye could not be assessed. Among 18 eyes with MMD stage 3, BMD and SRP prevalence was 3 of 18 (17%) and 2 of 18 (11%), respectively. Among 3468 BES participants, 8 eyes had MMD stage 4, with all eyes showing foveal BMDs and SRPs. Among 14 eyes with MMD stage 3, BMD and SRP prevalence was 10 of 14 (71%) and 7 of 21 (33%), respectively. Conclusions: All eyes with assessable myopic macular atrophy showed foveal BMDs associated with SRPs, while patchy atrophies could be differentiated into those with BMDs and SRPs and those without BMDs and without SRPs. Independent of the MMD stage, the prevalences of BMDs and SRPs were highly significantly associated with each other.

Optic neuropathy in high myopia: Glaucoma or high myopia or both?

Due to the increasing prevalence of high myopia around the world, structural and functional damages to the optic nerve in high myopia has recently attracted much attention. Evidence has shown that high myopia is related to the development of glaucomatous or glaucoma-like optic neuropathy, and that both have many common features. These similarities often pose a diagnostic challenge that will affect the future management of glaucoma suspects in high myopia. In this review, we summarize similarities and differences in optic neuropathy arising from non-pathologic high myopia and glaucoma by considering their respective structural and functional characteristics on fundus photography, optical coherence tomography scanning, and visual field tests. These features may also help to distinguish the underlying mechanisms of the optic neuropathies and to determine management strategies for patients with high myopia and glaucoma.

Effect of intraocular pressure reduction on progressive high myopia (PHM study): study protocol of a randomised controlled trial.

BACKGROUND: In adult patients with high myopia (HM), progressive axial elongation poses a significant risk for the development of subsequent ocular complications that may lead to visual impairment. Effective strategies to reduce or prevent further axial elongation in highly myopic adult patients have not been available so far. Recent studies suggested that medically lowering intraocular pressure (IOP) may reduce axial elongation. OBJECTIVE: This clinical randomised controlled trial (RCT) aims to evaluate the efficacy of medical IOP reduction in adult patients with progressive HM (PHM). TRIAL DESIGN: Single-centre, open-label, prospective RCT. METHODS: This RCT will recruit 152 participants with PHM at the Zhongshan Ophthalmic Center (ZOC). Randomised in a ratio of 1:1, participants will receive IOP-lowering eyedrops (intervention group) or will be followed without treatment (control group) for 12 months. Follow-up visits will be conducted at 1, 6 and 12 months after baseline. Only one eye per eligible participant will be included for analysis. The primary outcome is the change in axial length (AL) within the study period of 12 months. Secondary outcomes include the incidence and progression of visual field (VF) defects, changes in optic disc morphology and incidence and progression of myopic maculopathy. Difference in AL changes between the two groups will be analysed using linear regression analysis. For the secondary outcomes, a multifactor Poisson regression within a generalised linear model will be used to estimate the relative risk of progression in VF defects and myopic maculopathy, and the rate of thinning in retinal nerve fibre layer and ganglion cell-inner plexiform will be assessed through Kaplan-Meier curves and log-rank tests. ETHICS AND DISSEMINATION: Full ethics approval for this trial has been obtained from the Ethics Committee of ZOC, Sun Yat-sen University, China (ID: 2023KYPJ110). Results of this trial will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT05850936.

Unintentional injuries and falls in populations in Russia. The Ural eye and medical study and the Ural very old study.

Background: To explore the prevalence of self-reported unintentional injuries and falls (UIFs) in medium-aged and old populations in Russia and factors associated with them. Methods: Two population-based studies (Ural Eye and Medical Study (UEMS), Ural Very Old Study (UVOS)) were carried out urban and rural areas in Bashkortostan/Russia. They consisted of 5899 individuals (age: 40+ years) and 1526 participants (age: 85+ years), respectively. We assessed previous falls as part of an interview with standardized questions, conducted in the framework of a series medical and ophthalmological assessments. Results: In the UEMS with 5894 individuals (age:59.0 ± 10.7 years), UIF prevalence was 1101/5894 (18.7 %; 95 % confidence interval (CI)CI:17.7,19.7), with 1,2,3,4,5,6,7,8,9, or 10+ UIFs reported by 766 (69.6 %),146 (13.3 %),56 (1.4 %),15 (1.4 %),19 (1.7 %),3 (0.3 %),2 (0.2 %),1 (0.01 %), and 10 (0.9 %) participants, respectively. The UIFs had occurred as outdoor incidents (n = 594; 53.8 %), at home (n = 162; 14.7 %), on the road or traffic accidents (n = 109; 9.9 %), at work (n = 77; 7.0 %), during garden work (n = 24; 2.2 %) or as falls from a higher level (n = 17; 1.5 %) or from house roofs (n = 16; 1.4 %). In 100 (1.7 % of the total study population; 9.1 % of the group with UIFs) participants, low vision was reported as a major cause for the UIF. Higher UIF prevalence was associated (multivariable analysis) with older age (odds ratio (OR):1.01; 95%CI:1.005,1.02;P < 0.001), urban region of habitation (OR:1.59; 95%CI:1.37,1.85;P = 0.001), higher smoking package number (OR:1.01; 95%CI:1.004,1.01;P = 0.001), longer waist circumference (OR:1.01; 95%CI:1.002,1.01;P = 0.008), higher prevalence of a history of arthritis (OR:1.38; 95%CI:1.18,1.62;P < 0.001) and backache (OR:1.73; 95%CI:1.49,2.02;P < 0.001), and higher depression score (OR:1.05; 95%CI:1.03,1.07;P < 0.001). Out of 1525 UVOS participants (age:88.8 ± 2.9 years; range:85-103.1 years), the UIF prevalence was 780/1525 (51.1 %; 95%CI: 48.6, 53.6), with 390 (50.0 %), 116 (14.8 %), 49 (6.3 %), 12 (1.5 %), 8 (1.0 %), 2 (0.3 %), 4 (0.5 %), 1 (0.1 %), and 15 (1.9 %) participants reported about 1,2,3,4,5,6,7,8,9,or 10+ UIFs, respectively. The UIFs had occurred as outdoor incidents (n = 386; 25.3 %), at home (n = 214; 14.0 %), on the road or traffic accidents (n = 22; 1.4 %), at work (n = 21; 1.4 %), during garden work (n = 10; 0.7 %) or as falls from a higher level (n = 11; 0.7 %) or from house roofs (n = 1; 0.1 %). A higher UIC prevalence correlated with female sex (OR:1.65; 95%CI:1.30,2.09;P < 0.001) and Russian ethnicity (OR:1.26; 95%CI:1.02,1.56;P = 0.03). Conclusions: UIFs have occurred to a substantial part of the adult and very old population in Russia.

Progression Patterns and Risk Factors of Axial Elongation in Young Adults with Non-Pathologic High Myopia: Three-year Large Longitudinal Cohort Follow-up.

PURPOSE: To investigate the progression patterns and risk factors of axial elongation in young adults with non-pathologic high myopia. DESIGN: Prospective, clinical observational cohort study with 2- to 4-year follow-up. METHODS: A total of 1043 eyes of 563 participants (3515 medical records) aged 18 to 50 years with non-pathologic high myopia (axial length [AL] ≥ 26 mm; myopic maculopathy < diffuse chorioretinal atrophy; without posterior staphyloma) were included from 1546 participants (6318 medical records). Annual axial elongation was calculated via linear mixed-effect models. The associated risk factors of axial elongation were determined by ordinal logistic regression analysis, with generalized estimate equations for eliminating an interocular correlation bias. RESULTS: Based on 5359 times of AL measurements, the annual axial elongation of participants (mean [SD] age 31.39 [9.22] years) was 0.03 mm/year (95% confidence interval [CI], 0.03-0.04, P < 0.001) during a 30.23 (6.06) months' follow-up. Severe (> 0.1 mm/year), moderate (0.05-0.09 mm/year), mild (0-0.049 mm/year), and nil (≤ 0 mm/year) elongation was observed in 122 (11.7%), 211 (20.2%), 417 (40.0%), and 293 (28.1%) eyes. The following risk factors were significantly associated with axial elongation: baseline AL≥ 28 mm (odds ratio [OR], 4.23; 95%CI, 2.95-6.06; P < 0.001); age < 40 years (OR, 1.64; 95%CI, 1.18-2.28; P = 0.003); axial asymmetry (OR, 2.04; 95%CI, 1.26-3.29; P = 0.003), and women (OR, 1.52; 95%CI, 1.13-2.2.05; P = 0.006). Using anti-glaucoma medications was a protective factor (OR, 0.46; 95%CI, 0.27-0.79; P = 0.005), which slowed 75% of axial elongation from 0.04 (0.06) to 0.01 (0.06) mm/y (P < 0.001). CONCLUSIONS: Axial elongation continued in young adults with non-pathologic myopia. Risk factors included longer baseline AL and axial asymmetry, younger age, and woman. Topical use of anti-glaucoma medications may be useful to reduce ongoing axial elongation.

Rates of Choriocapillaris Microvascular Dropout and Macular Structural Changes in Glaucomatous Optic Neuropathy With and Without Myopia.

PURPOSE: To evaluate the association between rates of juxtapapillary choriocapillaris microvasculature dropout (MvD) change and rates of ganglion cell inner plexiform layer (GCIPL) loss in primary open-angle glaucoma (POAG) and glaucoma suspect eyes with and without myopia. DESIGN: Cohort study from clinical trial data. METHODS: 238 eyes from 155 POAG and glaucoma suspect patients were stratified into no-myopia (axial length (AL) ≤ 24 mm; n = 78 eyes), mild myopia (24 mm < AL ≤ 26 mm; n = 114 eyes), and high myopia (AL > 26 mm; n = 46 eyes). Eyes with a minimum of 3 visits and 1.5 years of follow-up with both optical coherence tomography angiography (OCT-A) and OCT macula scans were included. Presence, area, and angular circumference of juxtapapillary MvD were evaluated on en face choroidal images and horizontal B-scans obtained from OCT-A imaging. RESULTS: Over the mean follow-up of 4.4 years, the mean MvD area rates of change (95% CI) were largest in high and mild myopia group (0.04 [0.03, 0.05] mm2/year in both groups), followed by the no-myopia group (0.03 [0.02, 0.04] mm2/year). The mean MvD angular circumference rates of change (95% CI) were highest in mild myopia group (8.7° [6.9°, 10.5°]/year) followed by the high myopia and no-myopia groups (8.1° [5.3°, 10.9°]/year, and 7.4° [5.3°, 9.6°]/year, respectively). While the mean global GCIPL thinning rates between eyes with MvD at baseline compared to eyes without were similar in all myopia groups, the rates of MvD area change were significantly faster in all myopia groups with baseline MvD (all p ≤ 0.004). Significant faster rates of MvD angular circumference change were found in the mild myopia group with baseline MvD (P < .001) only. In multivariable models, the rates of GCIPL thinning over time were significantly associated with rates of MvD angular circumference change and MvD area change (R2 = 0.33, P < .001 and R2 = 0.32, P = .006, respectively). CONCLUSIONS: Rates of GCIPL thinning were associated with rates of MvD area and angular circumference change over time in myopic POAG eyes. Utilizing OCT-A to detect MvD may provide an additional tool for monitoring macular structural changes in glaucomatous eyes with myopia.

Prevalence and Associations of Keratoconus Among Children, Adults, and Elderly in the Population-Based Ural Eye Studies.

PURPOSE: To estimate prevalence and associations of keratoconus in populations in Russia with an age from childhood to seniority. METHODS: The study population consisted of the cohorts of 3 population-based studies performed in urban and rural areas within the same geographical region in Bashkortostan/Russia: the Ural Children Eye Study (UCES; age = 6-18 y; n = 4890), the Ural Eye and Medical Study (UEMS; age = >40 y; n = 5314), and the Ural Very Old Study (UVOS; age = >85 y; n = 651). Based on Scheimflug imaging, keratoconus was defined by a keratometric reading of ≥48 diopters (D) in any eye. RESULTS: The mean maximal and minimal corneal refractive power increased from the UCES (43.58 ± 1.50 D and 42.70 ± 1.42 D, respectively) to the UEMS (44.26 ± 1.70 D and 43.61 ± 1.76 D, respectively) and to the UVOS (45.1 ± 1.72 D and 43.98 ± 1.68 D, respectively). Correspondingly, keratoconus prevalence increased from the UCES (42/4890; 0.086%; 95% CI = 0.060, 0.112) to the UEMS (112/5314; 2.11%; 95% CI = 1.72, 2.49) and to the UVOS (42/651; 6.45%; 95% CI = 4.56, 8.34). In the UCES, higher keratoconus prevalence was associated (multivariable analysis) with higher birth order [odds ratio (OR) = 2.34; 95% CI = 1.32, 4.15; P = 0.004], lower birth weight (OR = 0.99; 95% CI = 0.99, 0.99; P < 0.001), and shorter axial length (OR = 0.15; 95% CI = 0.08, 0.30; P < 0.001). In the UEMS, keratoconus prevalence correlated with shorter axial length (OR = 0.15; 95% CI = 0.10, 0.23; P < 0.001), larger corneal volume (OR = 1.17; 95% CI = 1.09, 1.25; P = 0.001), thicker lens (OR = 2.27; 95% CI = 1.06, 5.28; P = 0.04), cortical cataract degree (OR = 1.02; 95% CI = 1.01, 1.04; P = 0.01), and higher stage of age-related macular degeneration (OR = 1.65; 95% CI = 1.09, 2.51; P = 0.02). In the UVOS, keratoconus prevalence correlated with lower educational level (OR = 0.84; 95% CI = 0.71, 0.99; P = 0.04) and lower dynamometric handgrip force (OR = 0.92; 95% CI = 0.88, 0.97; P = 0.003). CONCLUSIONS: In this study on multiethnic groups from Russia, keratoconus prevalence increased from the pediatric group (0.09%) to the adult group (2.11%) and seniority group (6.45%), correlated mostly with biometric ocular parameters and was in all age groups statistically independent of most systemic parameters.

Intraocular Amphiregulin antibody and axial elongation in nonhuman primates.

Purpose: To examine the effect of intraocularly applied amphiregulin antibody on physiological axial elongation in young nonhuman primates. Methods: The experimental study included six male 12-months-old macaque nonhuman primates (body weight:2.46 ± 0.25kg;range:2.20-2.90kg). In the experimental group (n=3 animals), three intravitreal injections of amphiregulin antibody (100µg/50µl) were applied to the left eyes at intervals of 4-6 weeks, and injections of phosphate buffered solution (50µl) were applied to the right eyes. Three other animals were assigned to a blank control group. Results: During the study period of 23.6 weeks, axial length in the experimental group did not change in the left eyes (18.91 ± 0.37mm to 18.94 ± 0.67mm;P=0.90), while it linearly increased in the right eyes (18.87 ± 0.38mm to 19.24 ± 0.53mm;P=0.056) and in the control group (left eyes:19.15 ± 0.22mm to 19.48 ± 0.22mm;P=0.009; right eyes:19.17 ± 0.15 mm to 19.46 ± 0.23 mm;P=0.024). The interocular difference in axial elongation increased in the experimental group from -0.11 ± 0.12mm at 4 weeks after baseline to -0.34 ± 0.15mm at the study end, while in the control group, the interocular side difference did not change significantly (from 0.01 ± 0.10 mm to 0.03 ± 0.08 mm;P=0.38). The difference in the interocular difference in axial elongation between the two groups was significant at 8 weeks (P=0.01), 15 weeks (P=0.007), and at study end (P=0.02). The interocular difference in axial length correlated with the interocular difference in vitreous cavity length (standardized regression coefficient beta:0.85;P<0.001). The interocular axial length difference was inversely associated with the interocular refractive error difference (beta:-0.49;P<0.001). Conclusions: Intraocularly applied amphiregulin antibody (100µg) reduced the physiological ocular axial elongation in juvenile nonhuman primates.