LONGITUDINAL CHANGES OF POSTERIOR VORTEX VEINS IN HIGHLY MYOPIC EYES DETERMINED BY RETROSPECTIVE ANALYSES OF INDOCYANINE GREEN ANGIOGRAMS.

PURPOSE: To assess the longitudinal changes of the posterior vortex veins (VVs) in highly myopic (HM) eyes. METHODS: The medical records of 1,730 consecutive HM eyes that had undergone indocyanine green angiography were studied. Eyes that had posterior VVs and had undergone at least two indocyanine green angiography examinations with a minimum interval of 3 years were selected from this group. RESULTS: Ninety-one eyes of 78 patients met the inclusion criteria. A total of 124 posterior VVs were identified. Over an average interval of 7.8 ± 5.0 years, 41 (33.1%) of the 124 posterior VVs had marked changes consisting mainly of an attenuation of vessels in 36 posterior VVs (87.8%) and alterations in the drainage course in 16 posterior VVs (39.0%). Fifteen posterior VVs had both types of changes. Most of the attenuations of the vessels occurred for smaller branches, but a complete loss of the entire trunk was seen in three eyes. Additionally, four eyes had posterior VV changes in association with changes of peripheral VVs. CONCLUSION: Posterior VV in highly myopic eyes can undergo changes with increasing time. The associated factors included the development and progression of myopic maculopathy lesions. In some cases, the blood drainage shifted from posterior VV to peripheral VV by forming anastomotic channels.

COMPLEX HEMODYNAMICS OF INTERVORTEX VEIN ANASTOMOSES IN HIGHLY MYOPIC EYES.

PURPOSE: To analyze the complex pattern of filling of the intervortex vein (IVV) anastomoses through large trunks in highly myopic eyes based on indocyanine green angiographic (ICGA) videos. METHODS: The medical records of 1,060 consecutive highly myopic eyes that had undergone ICGA were studied. IVV anastomoses were identified in the ICGA images, and the ICGA images and videos were analyzed comprehensively to characterize their hemodynamic features. RESULTS: Seven eyes with IVV anastomoses through large trunks were analyzed. In the ICGA videos of six eyes, laminar flow was observed in the IVV anastomotic vessels. The laminar flow started in the arterial phase in two eyes, with pulsatile fashion in 1 of them. The flow began in the early arteriovenous transition phase in four eyes. The laminar flow continued for a mean of 12.17 ± 3.06 seconds, and the remaining section was gradually filled slower than the surrounding veins. The anastomotic trunk for the remaining one eye was too narrow to be analyzed. Four eyes had longitudinal ICGA records, and two had significant attenuation and narrowing of the anastomotic vessels. CONCLUSION: The very early filling of part of the IVV anastomoses suggests that arteriovenous anastomoses are involved in the IVV of highly myopic eyes. However, this suggestion needs further study. There may be similar pathogenesis for IVV anastomoses either in thick or thin sclera.

ANOMALIES OF CHOROIDAL VENOUS STRUCTURE IN HIGHLY MYOPIC EYES.

PURPOSE: To identify anomalies of choroidal venous structure in highly myopic (HM) eyes. METHODS: Widefield indocyanine green angiographic images of 175 HM eyes (refractive error ≤ -6.0D diopters or axial length >26.5 mm) and 100 control eyes taken between January 2014 and December 2018 were reviewed. RESULTS: There were no significant differences in age and gender between HM patients and controls. Three types of changes of large choroidal veins were found in 103 HM eyes (58.86%): Asymmetry of vortex veins in 44 eyes (25.14%), isolated long vein across the macula in 58 eyes (33.14%), and intervortex anastomoses in 25 eyes (14.29%). Similar changes in controls were found in 12 eyes (12%), 0 eye (0%), and 2 eyes (2%), respectively, which were significantly lower than those in the HM group (all P < 0.05). The patterns of asymmetry were affected by steeper staphyloma edges and anastomoses were observed through large trunks and terminal venules. In two eyes with large trunk anastomosis, attenuation of the less dominant vortex vein was observed afterward. CONCLUSION: Choroidal venous anomalies are more common in HM eyes than controls. Choroidal venous structure in HM eyes may be altering continuously, and such changes may underlie the development of myopic maculopathy.

Validation of Soft Labels in Developing Deep Learning Algorithms for Detecting Lesions of Myopic Maculopathy From Optical Coherence Tomographic Images.

PURPOSE: It is common for physicians to be uncertain when examining some images. Models trained with human uncertainty could be a help for physicians in diagnosing pathologic myopia. DESIGN: This is a hospital-based study that included 9176 images from 1327 patients that were collected between October 2015 and March 2019. METHODS: All collected images were graded by 21 myopia specialists according to the presence of myopic neovascularization (MNV), myopic traction maculopathy (MTM), and dome-shaped macula (DSM). Hard labels were made by the rule of major wins, while soft labels were possibilities calculated by whole grading results from the different graders. The area under the curve (AUC) of the receiver operating characteristics curve, the area under precision-recall (AUPR) curve, F-score, and least square errors were used to evaluate the performance of the models. RESULTS: The AUC values of models trained by soft labels in MNV, MTM, and DSM models were 0.985, 0.946, and 0.978; and the AUPR values were 0.908, 0.876, and 0.653 respectively. However, 0.56% of MNV "negative" cases were answered as "positive" with high certainty by the hard label model, whereas no case was graded with extreme errors by the soft label model. The same results were found for the MTM (0.95% vs none) and DSM (0.43% vs 0.09%) models. CONCLUSIONS: The predicted possibilities from the models trained by soft labels were close to the results made by myopia specialists. These findings could inspire the novel use of deep learning models in the medical field.

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.

ROLE OF DILATED SUBFOVEAL CHOROIDAL VEINS IN EYES WITH MYOPIC MACULAR NEOVASCULARIZATION.

PURPOSE: To investigate the dilated choroidal veins (DCVs) at or around myopic macular neovascularizations (MNVs) and to determine whether there is a hemodynamic relationship between them. METHODS: Fifty-eight eyes of 57 patients with myopic MNVs were examined. Dilated choroidal veins were defined as choroidal veins whose diameter was 2X larger than adjacent veins. Indocyanine green angiography and swept-source optical coherence tomography images were reviewed to detect DCVs that crossed the subfoveal area. The filling sequence of the DCVs and MNVs was determined. RESULTS: Patients' mean age was 71.4 ± 10.6 years. The mean axial length was 29.3 ± 1.8 mm. Dilated choroidal veins below or around the MNV were found in 17 eyes (29.3%). Emissaries of the short posterior ciliary arteries were seen at or around MNVs in 8 of the 17 eyes. In these eyes, the short posterior ciliary artery was filled first or almost simultaneously with the filling of the MNV, followed by a laminar filling of the DCVs. In one eye, afferent arterioles from the short posterior ciliary arteries and efferent venules connected to DCVs were seen. CONCLUSION: Dilated choroidal veins are present below or around MNVs in about 30% of eyes with myopic MNVs. Our findings suggest that an MNV might be a vascular unit consisting of short posterior ciliary arteries, afferent arterioles, efferent venules, and DCVs.

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.

Ultrawide-Field OCT to Investigate Relationships between Myopic Macular Retinoschisis and Posterior Staphyloma.

PURPOSE: To investigate the relationships between myopic macular retinoschisis (MRS) and posterior staphylomas and to reveal the characteristics of other retinal lesions associated with MRS. DESIGN: Retrospective, observational case series. PARTICIPANTS: Seven hundred twenty-nine eyes of 420 patients with high myopia, which was defined as myopic refractive error of more than -8.0 diopters or an axial length longer than 26.5 mm. METHODS: Highly myopic eyes were examined by ultrawide-field (UWF) swept-source (SS) OCT with scan width of up to 23 mm and scan depth of 5 mm. The OCT features of MRS and posterior staphylomas and their spatial relationship were examined in UWF SS OCT images. MAIN OUTCOME MEASURES: Associations between MRS and staphylomas. RESULTS: In 729 eyes with mean axial length of 30.2±2.1 mm, posterior staphyloma was detected in 482 eyes (66.1%) and MRS was detected in 136 eyes (18.7%). All 136 eyes with an MRS showed outer retinoschisis, and 40 eyes (29.4%) also showed inner retinoschisis. Posterior staphyloma was detected significantly more frequently in eyes with MRS (117/136 [86.0%]) than in eyes without MRS (365/593 [61.6%]; P < 0.001). In all eyes with both staphyloma and outer retinoschisis, the area of the outer retinoschisis was restricted to the area within the staphyloma. In 1 of the 19 eyes with outer retinoschisis but without staphyloma, the outer retinoschisis extended beyond the range of the scanned fundus area. Among the 40 eyes with inner retinoschisis, the inner retinoschisis was located within the region of the outer retinoschisis in 39 eyes (97.5%). In all eyes with inner retinoschisis, retinal lesions causing an inward-directed tractional force were found within the area of the inner retinoschisis. CONCLUSIONS: In highly myopic eyes, the sites of the MRS and staphylomas were spatially related to each other. Posterior-directed force in association with staphylomas, and an inward-directed force resulting from epiretinal membranes or vitreoretinal attachments, may act as causative factors for MRS. However, the exact mechanisms related to the development of an MRS are probably diverse and complex.

Establishment of novel therapy to reduce progression of myopia in rats with experimental myopia by fibroblast transplantation on sclera.

Myopia is one of the most common visual disorders, and is characterized by a progressive axial elongation of the eye. Several methods have been tried to reduce the progression of axial elongation and myopia, but there are still no well-accepted procedures. We hypothesized that transplantation of fibroblasts on the sclera would lead to the synthesis of collagen fibrils on the sclera and reinforce it, and reduce the degree of axial elongation of eyes with form deprivation myopia. To examine this, we developed a form deprivation myopia model in albino Wistar rats and examined the effects of human fibroblasts (hFbs) transplantation on the sclera in the progression of myopia and axial elongation. We found that the form deprivation by eyelid suture induced a myopic shift and axial elongation associated with a thinner sclera and smaller-diameter collagen fibrils in Wistar rats. We also found that the transplanted hFbs synthesized type 1 collagen fibrils on the rat sclera, and these eyes with form deprivation had significantly reduced ocular elongation and myopic shift than the eyes without hFbs transplantation. Some of the synthesized collagen fibrils migrated into the sclera and had a bundle-like appearance and a stripe-like pattern, indicating they had mature characteristics. These findings suggest that the rat sclera was reinforced by the newly synthesized collagen fibrils and the axial elongation was reduced. These results can provide important information for the development of a therapy targeting myopia in humans. Copyright © 2017 John Wiley & Sons, Ltd.

Posterior Staphylomas in Pathologic Myopia Imaged by Widefield Optical Coherence Tomography.

Purpose: To examine posterior staphylomas by widefield optical coherence tomography (WF-OCT) and three-dimensional magnetic resonance imaging (3D-MRI). Methods: Highly myopic patients (myopic refractive error >8.0 diopters or axial length >26.5 mm) who had previously undergone orbital 3D-MRI were examined by WF-OCT. Results: The study included 100 eyes of 57 patients with a mean age of 67.9 ± 10.7 years (range, 44-85 years) and mean axial length of 30.0 ± 2.3 mm (range, 25.1-36.5 mm). All staphylomas detected on the 3D-MRI, except for two very large staphylomas, were visualized on the WF-OCT images. Morphologic hallmarks of the staphylomas were smoothly configured staphyloma border with a gradual thinning of the choroid and an inward protrusion of the sclera at the staphyloma edge. Comparing the detectability of the staphylomas on the WF-OCT images versus 3D-MRI revealed no significant difference between both techniques (P = 0.12; χ2 test). Comparing the staphyloma classification between both techniques showed a good concordance with a concordance index kappa of 0.61 (95% confidence interval: 0.50-0.72). A spatial relationship between the staphylomatous areas and the macula and optic nerve head was observed by WF-OCT. Conclusions: WF-OCT can provide tomographic images of posterior staphylomas in a resolution and size unachievable so far, and may replace 3D-MRI in assessing posterior staphylomas. Future studies using WF-OCT may explore the detailed morphologic characteristics of posterior staphylomas and give clues to the etiology of staphylomas.

Parapapillary Diffuse Choroidal Atrophy in Children Is Associated With Extreme Thinning of Parapapillary Choroid.

Purpose: To analyze morphologic features of segmental parapapillary diffuse choroidal atrophy (PDCA) in children. Methods: The study group included children (age ≤15 years) with high myopia who attended the Tokyo High Myopia Clinic. Control groups comprised participants of the population-based Gobi Desert Children Eye Study (GobiDCES). Fundus photographs were examined for presence of PDCA and choroidal thickness (CT) was measured by optical coherence tomography. Results: The study group included 41 eyes of 21 children with PDCA (mean age: 9.4 ± 3.7 years; mean refractive error: -11.5 ± 3.1 diopters) and the GobiDCES included 1463 children (age: 11.8 ± 3.5 years). In the study group, all eyes showed an extreme and abrupt thinning of the temporal parapapillary choroid. At 2500 µm nasal to the foveola, CT was <60 µm in 31 (76%) eyes of the study group but in none (0/1463) of the GobiDCES (P < 0.001), except for one child with PDCA. Conclusions: Parapapillary diffuse choroidal atrophy in children is associated with abrupt segmental thinning of the choroid in the temporal parapapillary region, in addition to the thinning of the subfoveal choroid after adjusting for refractive error and age.

Detection of posterior vortex veins in eyes with pathologic myopia by ultra-widefield indocyanine green angiography.

AIMS: To analyse the characteristics of posterior vortex veins detected in highly myopic eyes by wide-field indocyanine green angiography (ICGA). METHODS: One hundred and fifty-eight consecutive patients (302 eyes) with high myopia (myopic refractive error >8.0 dioptres (D) or axial length ≥26.5 mm) were studied. Wide-field ICGA was performed with the Spectralis HRA module. RESULTS: Posterior vortex veins were found in 80 eyes (26%). The prevalence of posterior staphyloma was significantly higher in eyes in which posterior vortex vein was detected than in eyes without posterior vortex vein. The posterior vortex veins were classified into five types according to the site of exit from the eye; around the optic nerve in 28%, in the macular area in 17%, along the border of staphyloma in 6%, along the margin of macular atrophy or large peripapillary conus in 21%, and elsewhere in 28%. In one eye, two posterior vortex veins collected the choroidal venous blood from the entire fundus. CONCLUSIONS: Wide-field ICGA can analyse the characteristic features of choroidal blood outflow system through posterior vortex veins in highly myopic eyes. They may play an important role as routes of choroidal outflow in highly myopic eyes.

FEATURES OF POSTERIOR STAPHYLOMAS ANALYZED IN WIDE-FIELD FUNDUS IMAGES IN PATIENTS WITH UNILATERAL AND BILATERAL PATHOLOGIC MYOPIA.

PURPOSE: Pigmentary alterations along the presumed edge of staphyloma in wide-field fundus images have been reported to be highly correlated with the eye shape in three-dimensional magnetic resonance images. The purpose of this study was to analyze Optos images in a large series of highly myopic patients to determine the prevalence, types, and features of staphylomas. METHODS: One thousand and sixty eyes of 541 patients with high myopia (axial length ≥ 26.5 mm) in at least one eye were retrospectively analyzed in Japan and Spain. To determine the presence and types of staphyloma, the authors focused on pigmentary abnormalities along the presumed edge of staphylomas with at least one positive finding in fundus images, autofluorescent images, and infrared images by Optos. RESULTS: Posterior staphyloma was detected in 552 of 1,060 eyes (55%) in Optos images. Wide macular type was the most common (79%), followed by narrow macular (15%), then peripapillary (3%), inferior, and finally nasal. In the 60 non-highly myopic eyes of patients with unilateral high myopia, staphyloma was detected in 40%, suggesting that unilateral high myopia might be a bilateral disorder with marked differences in the degree of staphyloma between the two eyes. Combined staphylomas such as the peripapillary type within the wide macular type were also found. CONCLUSION: Posterior staphyloma was found in 55% of 1,060 eyes with bilateral or unilateral pathologic myopia. Wide macular was the most common type, although there were much more variations in the shape of staphylomas than that had been previously believed.

Characteristics of higher-order aberrations and anterior segment tomography in patients with pathologic myopia.

PURPOSE: To investigate prospectively the characteristics in the higher-order aberrations and anterior segment tomography in patients with pathologic myopia. METHODS: One hundred and twelve consecutive highly myopic patients (mean age 43.4 ± 9.3 years, spherical equivalent of refractive error ≥8 D and an axial length ≥26.5 mm) were studied. Thirty-seven emmetropic individuals (mean age 37.0 ± 14.5 years, spherical equivalent of refractive error ≤ ±1 D) were analyzed as controls. The ocular and cornea higher-order aberrations were measured using a Hartmann-Shack wavefront sensor (KR-1W; Topcon Corporation, Tokyo, Japan). The crystalline lens rise, the angle-to-angle, and the white-to-white values were measured using anterior segment OCT (SS-1000; Tomey Corporation, Nagoya, Japan). The mean curvature of the anterior corneal surface, the thickness at the thinnest central corneal point, the location of the central corneal point, the corneal volume, the anterior chamber volume, and the anterior chamber depth were measured using the Pentacam HR (Oculus, Inc., Wetzlar, Germany). RESULTS: The ocular total higher-order aberration for 4-mm pupil, the ocular spherical aberrations, and internal spherical aberration for 6-mm pupil were significantly higher in highly myopic eyes than in the emmetropic controls. The crystalline lens rise was significantly smaller in highly myopic eyes than in the emmetropic controls. The anterior chamber depth and the anterior chamber volume were significantly larger in highly myopic eyes than in the emmetropic controls. CONCLUSION: Highly myopic eyes had higher-order aberrations than emmetropic eyes because of the increasing internal aberrations.

SIX-YEAR OUTCOMES OF INTRAVITREAL BEVACIZUMAB FOR CHOROIDAL NEOVASCULARIZATION IN PATIENTS WITH PATHOLOGIC MYOPIA.

PURPOSE: To investigate the 6-year outcome of intravitreal bevacizumab (IVB) to treat eyes with active choroidal neovascularization (CNV) due to pathologic myopia. METHODS: Medical records of 36 eyes of 35 consecutive patients with high myopia (refractive error ≥8 D or axial length ≥26.5 mm) and active CNV, who had been treated with IVB and followed for ≥6 years were analyzed. The factors that predicted the best-corrected visual acuity (BCVA) at 6 years after IVB were determined by multiple regression analyses. RESULTS: The mean age of the subjects was 58 years, and the mean axial length was 29 mm. Twenty-one eyes had subfoveal CNV and 15 eyes had nonsubfoveal CNV. During the 6-year follow-up, the mean number of IVB was 1.78. The mean BCVA logMAR (equivalent Snellen visual acuity) was 0.50 (20/63), 0.31 (20/40), 0.39 (20/50), and 0.45 (20/63) at the baseline, and at 2, 4, and 6 years after the IVB. The BCVA was significantly improved at 2 and 4 years compared with baseline values but not at 6 years. Stepwise multiple regression analyses showed that the BVCA at 6 years was significantly correlated with the size of the CNV-related macular atrophy, and the baseline BCVA and CNV size. CONCLUSION: The significant correlation between the BCVA at 6 years and the size of the macular atrophy indicates that treatments to prevent the development of macular atrophy are important for the long-term visual outcome in eyes with active CNV.

PERIPHERAL PIGMENTED STREAKS IN EYES WITH PATHOLOGIC MYOPIA.

PURPOSE: To determine the incidence and the characteristics of peripheral pigmented streaks in the eyes with pathologic myopia. METHODS: The widefield fundus images of 375 eyes (203 patients) with pathologic myopia were examined. The characteristics of the pigmented streaks existing in the peripheral fundus were analyzed. The spatial relationships between the steep edge of a staphyloma and the distribution of the streaks were also determined. RESULTS: Peripheral streaks were observed in 165 of the 375 eyes (44.0%) as dark, pigmented, radially oriented lesions resembling octopus tentacles. The streaks ran from the mid periphery to the equator. Large choroidal vessels were observed in the corresponding sites, so the streaks probably existed in the layer of the large choroidal vessels or deeper. The patients with streak lesions were significantly older and had a posterior staphyloma more frequently than the eyes without the streaks. The streaks were observed mainly in the area opposite the steep edge of a staphyloma. CONCLUSION: Peripheral pigmented streaks are seen in approximately 44% of eyes with pathologic myopia. The streaks existed in the layer of large choroidal vessels or deeper, and the thinning of the choroid-retina in highly myopic eyes contributes to the visibility of such deep lesions.

Characteristics of Peripapillary Staphylomas Associated With High Myopia Determined by Swept-Source Optical Coherence Tomography.

PURPOSE: To analyze the morphologic features of peripapillary staphylomas associated with high myopia by swept-source optical coherence tomography (OCT). DESIGN: Validity analysis. METHODS: Highly myopic patients (refractive error >8.0 diopters or axial length >26.5 mm) with a peripapillary staphyloma who had undergone swept-source OCT were studied. The non-highly myopic fellow eyes in patients with unilateral high myopia were also studied. The presence of a peripapillary staphyloma was determined by stereoscopic ophthalmoscopic examinations. The OCT features of the peripapillary staphylomas and other peripapillary lesions were evaluated. RESULTS: Twenty-five eyes of 16 patients were studied. Twenty-two eyes were highly myopic and the remaining 3 eyes of the patients with unilateral high myopia were non-highly myopic. A peripapillary staphyloma was seen in the swept-source OCT images as a gently sloping excavation around the optic disc in all 25 eyes. The posterior sclera in the area of a peripapillary staphyloma was observed to bow posteriorly, with the local curvature steeper than the curvature of the adjacent scleral regions. The sclera at the edge of a peripapillary staphyloma appeared to be elevated inward from the surrounding sclera, and the choroid at the staphyloma edge appeared to be compressed and thinned. A peripapillary intrachoroidal cavitation was a frequent complication and was found in 13 eyes with a peripapillary staphyloma (52.5%). CONCLUSIONS: Swept-source OCT can detect the slight changes of the sclera and choroid in the area of a peripapillary staphyloma, and we recommend its use in determining the presence of a peripapillary staphyloma.

Peripapillary Diffuse Chorioretinal Atrophy in Children as a Sign of Eventual Pathologic Myopia in Adults.

PURPOSE: To search for a morphologic biomarker to differentiate between pathologic myopia and simple childhood myopia. DESIGN: Retrospective case series. PARTICIPANTS: The study included children (age ≤15 years) with high myopia (as defined by the Japanese Ministry of Health and Welfare) who attended the High Myopia Clinic between April 1982 and March 1994, had undergone fundus photography, and had a follow-up of 20 years or more. METHODS: Fundus photographs obtained in childhood and adulthood were examined for presence of pathologic myopia, defined by high myopia (myopic refractive error >8 diopters or axial length ≥26.5 mm) and the presence of stage 2 or higher myopic maculopathy. MAIN OUTCOME MEASURES: Myopic maculopathy in childhood. RESULTS: The study included 56 eyes of 29 patients with a mean age of 10.2±3.6 years at the initial visit and an age of 36.0±7.6 years at the last visit. Mean axial length was 27.0±1.4 mm at baseline and 29.7±2.0 mm at the last visit. At the last visit, 19 eyes (34%) had tessellated fundus alone, 31 eyes (55%) had diffuse chorioretinal atrophy, 3 eyes (5%) showed patchy chorioretinal atrophy, and 1 eye (2%) had macular atrophy. Thus, 35 eyes (63%) had pathologic myopia in adulthood. Among the 35 eyes, 29 (83%) already had diffuse chorioretinal atrophy at the initial visit in childhood and the remaining 6 eyes (17%) showed tessellated fundus in childhood. The diffuse chorioretinal atrophy seen in childhood was restricted to the area temporal to the peripapillary region. CONCLUSIONS: The presence of peripapillary diffuse chorioretinal atrophy in children with high axial myopia may be an indicator for the eventual development of advanced myopic chorioretinal atrophy in later life. These features in children may be helpful for differentiating simple childhood myopia from eventual pathologic myopia.

[Side Effects of Low Dose Atropine].

PURPOSE: Because highmyopia causes severe visual impairment, it is important to prevent the progression of myopia. Recently, the prevention of myopia progression by low dose atropine was reported from Singapore. We started the study of low dose atropine in Japanese children, with the aim of investigating the side effects of low dose atropine. SUBJECT AND METHODS: The participants were 16 children between the age of 6 and 12. They receive 0.01% atropine once nightly in both eyes. Refractive error, distant vision, near vision, accommodation and pupil diameter were checked before (baseline) and two weeks after the treatment (second baseline). Also, we checked subjective symptoms and adverse events. RESULTS: There was no significant change between baseline and second baseline in the refractive error, distant vision, near vision. Accommodation decreased mean 1.5 D (p < 0.01) and the pupil diameter was mean 0.7 mm larger (p < 0.0001), but the subjective symptoms were minimal. Accommodation and pupil diameter showed significant changes. Severe subjective symptoms and adverse events were not found in any of the cases. CONCLUSION: The side effects of low dose atropine were not severe. The treatment could be continued for the prevention of myopia.