The sequence of events in six years of a myopic traction maculopathy

PurposeTo investigate prognostic factors related to the surgical outcome of vitrectomy in myopic traction maculopathy (MTM).MethodsMedical records of patients with MTM who underwent pars plana vitrectomy with internal limiting membrane peeling and follow-up over 12 months were reviewed retrospectively. Best-corrected visual acuity (BCVA), fundoscopic examination and spectral-domain optical coherence tomography findings were evaluated postoperatively. Functional success was defined as visual acuity gain and anatomical success was defined as reduction or resolution of foveoschisis without complications.ResultsThis study included 40 eyes of 36 patients. BCVA improved from 0.70 ± 0.44 to 0.63 ± 0.57 logarithm of minimum angle of resolution and central macular thickness decreased from 526.6 ± 132.1 to 277.8 ± 92.1 µm at final follow-up. Functional success was achieved in 24 (60.0%) eyes, and 33 (82.5%) eyes reached anatomical success. Presence of foveal detachment (FD) and higher category of myopic maculopathy were associated with both functional (p = 0.014, 0.021, respectively) and anatomical (p = 0.011, 0.022, respectively) failure. Longer preoperative axial length showed an association with functional failure but not with anatomical failure (p = 0.041). In multivariate analysis, FD was the only prognostic factor for both functional and anatomical outcome (p = 0.041, 0.043, respectively). Preoperative BCVA (r2 = 0.259, p = 0.001), axial length (r2 = 0.172, p = 0.008), and myopic maculopathy category (r2 = 0.336, p < 0.001) showed significant correlation with final BCVA.ConclusionsMore severe myopic maculopathy and the presence of FD are associated with poorer functional and anatomical outcomes of pars plana vitrectomy in MTM. Better preoperative BCVA, shorter axial length, and less severe myopic maculopathy are correlated with better final BCVA.

Myopic maculopathy is the primary cause of irreversible visual impairment in patients with pathologic myopia, and myopic traction maculopathy often requires vitrectomy for treatment. Myopic traction maculopathy encompasses epiretinal membrane, foveoschisis, macular hole, and macular hole-related retinal detachment. It is recommended to perform vitrectomy combined with inner limiting membrane peeling for Type II epiretinal membrane, foveal-sparing inner limiting membrane peeling for foveoschisis, inverted inner limiting membrane flap technique for macular hole, and vitrectomy combined with macular buckle for refractory macular hole-related retinal detachment. Myopic traction maculopathy is a chronically progressive condition, and surgeons need to accurately determine the timing of surgery and choose appropriate procedures to maximize the benefits for patients.

PurposeTo investigate the percentages and risk factors for visual impairment (VI) across age groups in a highly myopic cohort with a wide range of age (18–93 years).MethodsA total of 2099 eyes (1220 participants) were enrolled. All participants underwent detailed ocular examinations. Myopic maculopathy (MM) was assessed as myopic atrophy maculopathy (MAM), myopic traction maculopathy (MTM) or myopic neovascular maculopathy (MNM) based on the ATN system.ResultsMost participants younger than 50 years had normal vision, while the cumulative risk of VI and blindness gradually increased after 50–59 years. The percentage of each type of MM increased nonlinearly with ageing (all p < 0.001), with an accelerated period of increase after 45 years for MAM, and after 50 years for MTM and MNM. Axial length (AL) ≥30 mm was the only associated factor for mild VI or worse in participants aged 18–39 years (p < 0.001). Older age, AL ≥30 mm and the presence of MAM were predictors for mild VI or worse in the group aged 40–49 years (all p < 0.05). In participants aged ≥50 years, older age, female sex, longer AL and increased severity of MM were risk factors for VI and blindness (all p < 0.05).ConclusionThe percentages of MM and related VI increased nonlinearly with older age, with a turning point at 45 years for MAM, preceding that of MTM, MNM and VI by 5 years, warranting future longitudinal studies to confirm. Different age groups presented different risk factors for VI. Timely screening should be in place for middle‐aged high myopes.

Myopic traction maculopathy (MTM) is a condition characterized by retinal complications due to excessive axial elongation in myopic eyes. Posterior scleral reinforcement (PSR) stabilizes the posterior pole by mechanically supporting the thinned sclera, limiting further axial elongation, and reducing macular traction. This study evaluates the efficacy of PSR in patients diagnosed with MTM. This study included patients with myopic traction maculopathy (MTM) who underwent posterior scleral reinforcement (PSR) between September 2020 and February 2023. Inclusion criteria were high myopia (HM; spherical equivalent [SE] ≤ - 6.00 diopters [D] or axial length [AL] ≥ 26mm) with documented progression ( ≥ - 1.00 D/year or > 0.5mm/year) and optical coherence tomography (OCT)‑confirmed myopic retinoschisis, macular hole, or macular detachment (MD). Exclusion criteria included prior refractive surgery, significant lens opacity, glaucoma, ocular trauma, or other vision‑threatening retinal diseases. Pre‑ and postoperative evaluations included best‑corrected visual acuity (BCVA), SE, AL, retinal thickness (RT), and choroidal thickness (CT) measured by OCT. PSR was performed using a bovine pericardium graft placed along the posterior sclera without pars plana vitrectomy (PPV). This single-arm retrospective study included 19 patients (21 eyes) with a mean follow-up of 7.43 ± 5.35 months. Preoperatively, the mean AL was 29.86 ± 2.24mm, the mean SE was - 12.43 ± 7.83 D, the mean BCVA was 0.39 ± 0.29, and the mean CT was 79.71 ± 14.71μm. At 6 months postoperatively, significant improvements were observed in BCVA (P < 0.05) and AL (P < 0.001), with AL demonstrating a statistically significant reduction from baseline. Additionally, CT increased by an average of 5.33 ± 11.29μm (P < 0.05). RT measurements showed a reduction across all regions, with the nasal sector reaching statistical significance (P < 0.05). No significant changes were noted between 1 and 6 months in AL, SE, BCVA, or CT (P > 0.05). At the extended follow-up of 12 and 18 months, anatomical and functional outcomes remained stable compared with the 6-month results, with no additional postoperative complications detected. The beneficial effects of PSR on axial length stabilization and choroidal thickening were maintained for up to 18 months without further progression or deterioration. PSR may help reduce posterior pole traction in MTM and is associated with both anatomical and functional improvements, including better BCVA and favorable changes in AL, SE, CT, and RT. Future studies with larger sample sizes and prospective, controlled designs are warranted to validate these findings and assess the long‑term durability of PSR.

To investigate the prevalence and risk factors of posterior staphyloma using wide-field optical coherence tomography (WF-OCT) in adults with high myopia in Singapore. Population-based cross-sectional study. Adults with spherical equivalent (SE)≤-5D in either eye at the first visit of Singapore Epidemiology of Eye Diseases study and Singapore Prospective Study Program study were recruited. Posterior staphyloma was diagnosed using WF-OCT (PLEX® Elite9000, Carl Zeiss Meditec). Myopic macular degeneration (MMD), myopic traction maculopathy (MTM) and vision-related quality of life (VRQoL) were assessed using fundus photographs, DRI-Triton OCT (Topcon) and the Impact of Vision Impairment (IVI) questionnaire, respectively. Factors associated with posterior staphyloma were identified with multilevel, multivariable logistic regression. Impact of posterior staphyloma on MMD, MTM and visual function was analysed with multilevel, multivariable logistic regression and linear mixed model, respectively. Among the 225 eyes [mean SE=-6.5±2.2 D, mean axial length (AL)=26.2±1.5mm] of 117 participants (mean age=60.3±7.1years), posterior staphyloma was detected in 47 (20.9%) eyes of 38 (32.5%) participants. Older age [odds ratio (OR), 1.18; 95% confidence interval (CI), 1.10-1.26], more myopic SE (0.63; 0.51-0.77) and increased AL (2.51; 1.69-3.73) were associated with higher prevalence of posterior staphyloma (all p<0.001). Adults with posterior staphyloma had higher odds of MMD (2.67; 1.23-5.82; p=0.013), MTM (3.79; 1.13-12.68; p=0.031) and worse IVI Reading (β=-1.44; -2.31 to 0.58; p=0.001) scores. About one in three adults with high myopia had posterior staphyloma, which was associated with increased odds of having myopic maculopathy and a detrimental impact on VRQoL.

PurposeThe purpose of this study was to engineer deep learning (DL) models that can identify myopic maculopathy in patients with high myopia based on optical coherence tomography (OCT) images.MethodsAn artificial intelligence (AI) system was developed using 2342 qualified OCT macular images from 1041 patients with pathologic myopia admitted to the Affiliated Eye Hospital of Wenzhou Medical University (WMU). We adopted an ResNeSt101 architecture to train five independent models to identify the following five myopic maculopathies: macular choroidal thinning, macular Bruch membrane (BM) defects, subretinal hyper-reflective material (SHRM), myopic traction maculopathy (MTM), and dome-shaped macula (DSM). We tested the models with an independent test dataset that included 450 images obtained from 297 patients with high myopia. Focal loss was used to address class imbalance, and optimal operating thresholds were determined according to the Youden Index. The performance was quantified using the area under the receiver operating characteristic (AUC), sensitivity, specificity, and confusion matrix.ResultsFor the identification of myopic maculopathy, the AUCs of receiver operating characteristic (ROC) curves were 0.927 to 0.974 for 5 myopic maculopathies. Our AI system achieved sensitivities equal to or even better than those of junior retinal specialists (56.16–99.73%). The diagnosis of it is also interpretable that we provide visual explanations clearly via heatmaps.ConclusionsWe developed a convolutional neural network (CNN)-based DL AI system for detection and classification of myopic maculopathy in patients with high myopia using OCT macular images. Our AI system achieved sensitivities equal to or even better than those of junior retinal specialists.Translational RelevanceThis AI system can be widely applied in sophisticated situations in large-scale high myopia screening.

Myopic traction maculopathy (MTM) is characterized by retinal thickening, retinoschisis, lamellar macular hole, and foveal retinal detachment and is a major cause of visual impairment in high myopia. As MTM may progress to full-thickness macular hole and macular hole retinal detachment during its natural course, vitreous surgery is effective in preventing these conditions and consequent severe vision loss. A 25-gauge pars plana vitrectomy with internal limiting membrane (ILM) peeling is the standard treatment for MTM, resulting in the improvement or maintenance of vision in most cases. However, opening of the macular hole occurs in 5–10% of eyes that undergo vitrectomy for MTM. Recently, fovea-sparing ILM peeling has been shown to be effective in preventing the development of macular hole associated with standard ILM peeling. This chapter focuses on the recent advances in the treatment of MTM.

To compare the progression of myopic maculopathy in patients with stage 3 myopic traction maculopathy (MTM) undergoing either pars plana vitrectomy (PPV) or macular buckling (MB). A total of 61 eyes diagnosed with stage 3 MTM were retrospectively divided into two groups: PPV group (30 eyes) and MB group (31 eyes). Best-corrected visual acuity (BCVA), axial length (AL), myopic maculopathy progression, retinal and choroidal thickness were measured and compared. The mean follow-up period was 70.9±13.67 months. The average myopic maculopathy stage in the PPV group progressed from 1.87±0.57 to 2.4±0.72 (P < 0.001). In the MB group, the stage advanced from 2.03±0.66 to 2.1±0.7 (P = 0.5). Progression to a different stage occurred in 14 eyes (46.67%) in the PPV group, compared to only 2 eyes (6.45%) in the MB group. 16.67% of eyes in the PPV group (5 out of 30) and 6.45% of eyes in the MB group (2 out of 31) showed progression within the same MM stage. Additionally, 9 eyes (29.03%) in the MB group exhibited retinal pigment epithelium injury adjacent to the macular buckle ridge (MB-related atrophy). Postoperatively, foveal retinal thickness (197.8±61.53 μm vs. 164.4±49.07 μm, P = 0.02) and central choroidal thickness (81.95±47.7 μm vs. 61.44±50.77 μm, P = 0.032) were significantly greater in the MB group. For patients with stage 3 MTM, PPV may accelerate the progression of myopic maculopathy, whereas MB may not. Therefore, MB may be a preferable surgical option for these patients.

An evidence-based review of the epidemiology of myopic traction maculopathy

Pathologic myopia (PM) is an ocular disorder characterized by a spherical equivalent (SE) of more than – 6.0 diopters (D) or by an axial length (AL) of more than 26.5 millimeters (mm). PM is associated with myopic maculopathy (MM). The ATN classification describes all the aspects of MM which regroups atrophic, tractional and neovascular consequences to the sclera, choroid and retina of highly myopic eyes. The advent of OCT allowed to define the ultrastructural characteristics of the tractional changes in MM, described by the term myopic traction maculopathy (MTM). They include foveoschisis/maculoschisis/retinoschisis (FS/MS/RS), retinal/foveal detachment (RD/FD), lamellar macular holes (LMH) and full-thickness macular holes (FTMH) with or without RD (MHRD). The MTM staging system (MSS) describes all foveal and retinal changes related to MTM and their natural history interpreting them as different stages of a single progressive disorder. The management of MTM can be just observation for the earliest cases with good vision or surgery for the severe stages with vision loss. There are two possible surgical approaches: ab externo, that acts on the alteration of the scleral shape and includes posterior scleral reinforcement and macular buckle. Ab interno, that targets the alteration of the foveal profile and consists in pars plana vitrectomy with removal of all the epiretinal tractions, maneuvers on the internal limiting membrane, and the use of intravitreal tamponade and laser. As they target two different sides of the same pathology, the two techniques have to be selected on the base of the MTM stage, single or combined.

Biomarkers in the pathogenesis of epiretinal membrane and myopic traction maculopathy: Effects of internal limiting membrane incompliance and posterior staphyloma.

To investigate the pace of visual acuity loss in myopic maculoschisis eyes with or without macular detachment and identify associated risk factors. One thousand three hundred and thirty-four eyes of 991 patients with high myopia were reviewed. A new myopic traction maculopathy staging system classified four retinal stages and three foveal stages. To the myopic traction maculopathy eyes with normal fovea, maculoschisis with and without macular detachment was defined as Stage 3a and Stages 1a, 2a respectively. One hundred and ten (8.25%) eyes with maculoschisis were included, with a follow-up of 24.00 ± 17.47 months. Of them, 84 (76.36%) were Stages 1a, 2a, and 26 (23.64%) were Stage 3a. The visual acuity loss per year during the follow-up period was similar between eyes with Stages 1a, 2a and Stage 3a (3.13 ± 12.21 vs. 3.41 ± 18.42 letters, P = 0.930). Multivariate analyses revealed that vitreomacular interface factors were significantly associated with visual acuity loss during the follow-up, no matter in Stages 1a, 2a or Stage 3a ( P = 0.039 and P = 0.038, respectively). In the Stages 1a, 2a group, the percentage of eyes that lost at least 10 letters at the final visit compared with the baseline visual acuity was higher in eyes with vitreomacular interface factors than in those without vitreomacular interface factors (13 eyes, 50.00% vs. 14 eyes, 24.14%, P = 0.019). No differences were found in visual acuity loss pace between Stages 1a, 2a and Stage 3a. Surgical intervention or at least more intensive follow-up should be considered for Stages 1a, 2a eyes with vitreomacular interface factors, to promote a more favorable visual outcome.

To describe a comprehensive OCT-based classification of myopic traction maculopathy (MTM). Two hundred eighty-one eyes with MTM (visited from 2006 to 2018), were retrospectively reviewed for age, best-corrected-visual-acuity (BCVA), axial length (AL), optical coherence tomography (OCT), and wide-field color fundus-photographs. The study was divided in two Phases. Phase 1: MTM types were categorized with OCT and correlated with age and BCVA. The type of staphyloma was described. Phase 2: the evolution of MTM was studied evaluating at least three OCT exams of each eye taken at different timings (interval between each exam: 1-10 years). Phase 1: We identified, four MTM retinal stages (1. Inner/Outer Maculoschisis; 2. Predominantly outer Maculoschisis; 3. Maculoschisis-Macular Detachment; 4. Macular Detachment) and three foveal stages (a. Normal fovea; b. Inner Lamellar-Macular-Hole; c. Full-Thickness-Macular-Hole). Outer-Lamellar-Macular-Holes and epiretinal abnormalities were associated findings. Stages 1 to 2 were younger than stages 3 to 4 (p < 0.05). BCVA in stages 1, 2 was similar, and higher than stages 3, 4 (p < 0.02). About 14% of eyes had no staphyloma, 73% of eyes had staphyloma type 1 or 2. MTM stages were not correlated with AL. Phase 2: The retina could change in time from stage 1 to 4, or the fovea could change from stage a to c. Mean evolution time from stage 1 to 2, stage 2 to 3, and 3 to 4 were 20, 12, 3 months, respectively. BCVA decreased over time as stages increased (p = 0.47). The MSS Table displays a new classification, the natural evolution, and practical insights for the management of MTM.

Recently, qualitative and quantitative perfusional evaluations of vessel density (VD) and choriocapillaris flow patterns at the macular level have changed the evaluation spectrum and management of different macular pathologies. Published data on long-term macular perfusional findings and quantitative VD and flow evaluation (perfusion indices) in patients at different stages of successfully operated myopic traction maculopathy (MTM) compared with the corresponding values in normal control subjects are limited. This chapter describes the role of macular perfusion as a contributing factor to the pathogenesis of MTM.&lt;br&gt;&lt;br&gt;The primary outcome measure included the long-term structural and perfusional macular status across groups. Forty-six eyes of 34 patients were included in the study group. The axial length was 29.89±1.67 mm. The postoperative follow-up period was 43±26.77 months. The preoperative BCVA was 1.29±0.54 logMAR, and the postoperative BCVA was 0.60±0.52 logMAR (P&amp;lt;0.05). The difference in perfusion indices across groups was statistically significant (p&amp;lt;0.005). Surgically resolved MTM eyes generally had a larger superficial foveal avascular zone area, lower vessel density, smaller choriocapillaris flow area (CFA), thinner central subfoveal thickness (CSFT), and more macular defects. Better functional, structural, and perfusion index outcomes were observed in highly myopic eyes that underwent early surgery.

Three cases of macular retinal detachment exacerbated during follow-up with myopic foveoschisis around myopic choroidal neovascularization