Bruch's Membrane Defects Research Articles

Prevalence and associations of dome-shaped maculas. The Beijing Eye Study.

To explore the prevalence and associated factors of a dome-shaped macula (DSM) in a general population. Out of the population-based Beijing Eye Study cohort (n = 3468 participants), the investigation included all eyes with an axial length of ≥25 mm, and a randomized sample of eyes with an axial length of <25 mm. Using optical coherence tomographic (OCT) images, we examined presence and height of DSMs, defined as an inward convexity of the foveal retinal pigment epithelium (RPE)/Bruch's membrane (BM) line, detectable in at least two OCT scans perpendicularly orientated to each other. The study cohort consisted of 366 eyes (314 individuals) with a mean age of 63.7 ± 9.7 years and a mean axial length of 24.8 ± 2.1 mm (median: 25.1 mm; range: 18.96-30.88 mm). Prevalence of DSMs (found in 6/366 eyes; 1.9%; 95%CI: 1.0, 3.0) increased from 0/125 (0%) in non-myopic eyes to 1/152 (0.7%; 95%CI: 0.0, 2.0) in moderately myopic eyes, and to 6/83 (7.2%; 95%CI: 1.7, 12.7) in the highly myopic group. In multivariable analysis, higher DSM prevalence corelated with longer axial length (OR: 2.05; 95%CI: 1.36, 3.08; p < 0.001) and higher stage of myopic macular degeneration (OR: 1.08; 95%CI: 1.01, 1.16; p = 0.03). The mean maximal DSM height was 139 ± 107 μm (median: 100 μm; range: 25-350 μm). It was associated with higher stage of myopic macular degeneration (beta: 0.24; p < 0.001) and higher prevalence of macular BM defects (beta: 0.17; p < 0.001). None of the DSMs showed a serous retinal detachment or relative choroidal thickening. Higher DSM prevalence correlated non-linearly with longer axial length, with DSM height increasing with the presence of a BM defect. DSMs may be associated with an axial elongation-related BM overproduction in the fundus midperiphery in all meridians.

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

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. 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. 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. 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.

Clinical and histological characteristics of axial myopia

Myopic axial elongation is associated with various non‐pathological changes. These include a decrease in photoreceptor cell and retinal pigment epithelium (RPE) cell density and retinal layer thickness, mainly in the retro‐equatorial to equatorial regions; choroidal and scleral thinning pronounced at the posterior pole and least marked at the ora serrata; and a shift in Bruch's membrane opening (BMO) occurring in moderately myopic eyes and typically in the temporal/inferior direction. The BMO shift leads to an overhang of Bruch's membrane (BM) into the nasal intrapapillary compartment and BM absence in the temporal region (i.e., parapapillary gamma zone), optic disc ovalization due to shortening of the ophthalmoscopically visible horizontal disc diameter, fovea–optic disc distance elongation, reduction in angle kappa, and straightening/stretching of the papillomacular retinal blood vessels and retinal nerve fibres. Highly myopic eyes additionally show an enlargement of all layers of the optic nerve canal, elongation and thinning of the lamina cribrosa, peripapillary scleral flange (i.e., parapapillary delta zone) and peripapillary choroidal border tissue, and development of circular parapapillary beta, gamma, and delta zone. Pathological features of high myopia include development of macular linear RPE defects (lacquer cracks), which widen to round RPE defects (patchy atrophies) with central BM defects, macular neovascularization, myopic macular retinoschisis, and glaucomatous/glaucoma‐like and non‐glaucomatous optic neuropathy. BM thickness is unrelated to axial length. Including the change in eye shape from a sphere in emmetropia to a prolate (rotational) ellipsoid in myopia, the features may be explained by a primary BM enlargement in the retro‐equatorial/equatorial region leading to axial elongation.

Myopia: Histology, clinical features, and potential implications for the etiology of axial elongation.

Myopic axial elongation is associated with various non-pathological changes. These include a decrease in photoreceptor cell and retinal pigment epithelium (RPE) cell density and retinal layer thickness, mainly in the retro-equatorial to equatorial regions; choroidal and scleral thinning pronounced at the posterior pole and least marked at the ora serrata; and a shift in Bruch's membrane opening (BMO) occurring in moderately myopic eyes and typically in the temporal/inferior direction. The BMO shift leads to an overhang of Bruch's membrane (BM) into the nasal intrapapillary compartment and BM absence in the temporal region (i.e., parapapillary gamma zone), optic disc ovalization due to shortening of the ophthalmoscopically visible horizontal disc diameter, fovea-optic disc distance elongation, reduction in angle kappa, and straightening/stretching of the papillomacular retinal blood vessels and retinal nerve fibers. Highly myopic eyes additionally show an enlargement of all layers of the optic nerve canal, elongation and thinning of the lamina cribrosa, peripapillary scleral flange (i.e., parapapillary delta zone) and peripapillary choroidal border tissue, and development of circular parapapillary beta, gamma, and delta zone. Pathological features of high myopia include development of macular linear RPE defects (lacquer cracks), which widen to round RPE defects (patchy atrophies) with central BM defects, macular neovascularization, myopic macular retinoschisis, and glaucomatous/glaucoma-like and non-glaucomatous optic neuropathy. BM thickness is unrelated to axial length. Including the change in eye shape from a sphere in emmetropia to a prolate (rotational) ellipsoid in myopia, the features may be explained by a primary BM enlargement in the retro-equatorial/equatorial region leading to axial elongation.

Using a combination of peripapillary atrophy area and choroidal thickness for the prediction of different types of myopic maculopathy.

To analyse the topographic characteristics in macular choroidal thickness (mChT) and ocular biometry in myopic maculopathy and to explore the potential cut-off value for prediction of myopic maculopathy (MM). All participants underwent detailed ocular examinations. MM was subdivided into thin choroid, Bruch's membrane (BM) defects, choroidal neovascularization (CNV), and myopic tractional maculopathy (MTM) according to OCT-based classification system. Peripapillary atrophy area (PPA), tilt ratio, torsion, and mChT were individually measured. A total of 1947 participants were included. In multivariate logistics models, older age, longer axial length, larger PPA area, and thinner average mChT were more likely to have MM and different type of MM. Female participants were more likely to have MM and BM defects. A lower tilt ratio was more likely to be associated with CNV and MTM. The area under the curve (AUC) of single tilt ratio, PPA area, torsion, and topographic of mChT for MM, thin choroid, BM Defects, CNV, and MTM were 0.6581 to 0.9423, 0.6564 to 0.9335, 0.6120 to 0.9554, 0.5734 to 0.9312, 0.6415 to 0.9382, respectively. After combining PPA area and average mChT for predicting MM, thin choroid, BM defects, CNV, and MTM, the AUC of the combination were 0.9678, 0.9279, 0.9531, 0.9213, 0.9317, respectively. Progressive and continuous PPA area expanding and thin choroid play a role in the development of myopic maculopathy. The present study showed that a combination of peripapillary atrophy area and the choroidal thickness could be used to predict MM and each type of MM.

Myopic macular Bruch's membrane defects

AbstractPurpose: To examine peculiarities of macular Bruch's membrane defects (BMD) in axially elongated eyes.Methods: Using light microscopy, enucleated human globes were histomorphometrically.Results: The study included 247 eyes (axial length: 20.0–37.0 mm). BMDs were detected in 15 (6.1%) eyes (axial length: 30.6 ± 2.4 mm) (1.9 ± 0.9 BMD/eye with BMDs), located in the macular region in 10 eyes. Mean BMD size was 1.93 ± 1.62 mm (range: 0.22 mm–6.24 mm). Prevalence and size of BMDs were associated with longer axial length (OR: 1.52; p = 0.001) and higher prevalence of scleral staphyloma (OR: 16.3; p &lt; 0.001). BMD width was smaller than the defect width in the overlying retinal pigment epithelium (RPE) layer (p = 0.003) and larger than the length of a defect in the overlying inner nuclear layer (0.43 ± 0.76 mm; p = 0.008) and the width of an inner limiting membrane bridge (0.13 ± 0.33 mm; p = 0.001). Choriocapillaris thickness (8.8 ± 5.0 μm vs. 7.9 ± 3.2 μm; p = 0.94), BM thickness (3.1 ± 0.6 μm versus 3.0 ± 0.5 μm; p = 0.43) and RPE cell density (31.6 ± 8.4 cells/480 μm vs. 27.4 ± 8.8 cells/480 μm; p = 0.051) did not differ significantly between the region at the BDM margin and neighbouring regions. The sclera was thinner in the BDM region than in the neighbouring regions (0.28 ± 0.19 mm vs. 0.36 ± 0.13 mm; p = 0.006).Conclusions: BMDs as hallmark of myopic macular degeneration are characterized by a larger defect in the overlying RPE layer, smaller defects in the overlying retinal outer nuclear layer and inner nuclear layer, localized scleral thinning and an association with scleral staphylomas. Thickness of the choriocapillaris and density of the RPE cell layer, both absent within the BDMs, do not differ between the BMD margin and neighbouring regions. The results suggest an association between BDMs and absolute scotomas, stretching of the overlying retinal nerve fiver layer, an axial elongation‐associated stretching effect as aetiology of the BDMs, and a biomechanical role BM may play.

ATN grading system in a dome‐shaped macula and ridge shaped macula high lymyopic cohort

AbstractPurpose: The purpose of this study was to analyse the ATN grading in highly myopic patients with dome‐shaped macula (DSM) and ridge‐shaped macula (RSM).Methods: This was a cross‐sectional, noninterventional study. 57 eyes of 38 different patients were included. They were classified as DSM or RSM based on the number of radial scans affected on the swept‐source optical coherence tomography (SS‐OCT) (12 = DSM; 12 = RSM). All patients underwent a complete ophthalmological examination in addition to SS‐OCT. They were graded using the ATN system for myopic maculopathy by 2 masked retina specialists that assessed the atrophic (A), tractional (T), and neovascular (N) components. As complementary measurements, age, axial length (AL) and best corrected visual acuity (BCVA) were collected. Height and orientation of the macular bulge and the presence of Bruch's membrane defects, scleral perforating vessels and staphyloma were recorded.Results: Out of total 57 eyes, 13 eyes (22.8%) were classified as DSM. Regarding the atrophic component (A), there were statistically significant differences between groups, with DSM group showing a greater stage of atrophy (predominantly stage A3 in 69.2% of the sample) compared to the RSM group (predominantly stage A2 in 61.3% of the sample) (p &lt; 0.05). As for the tractional (T) and neovascular (N) components, there were no significant differences between groups. The presence of Bruch's membrane defects was more frequently seen in DSM (p &lt; 0.05).Conclusions: DSM group showed more Bruch's membrane defects and a greater stage of the atrophy component, based on the ATN grading system, compared with RSM group. As Bruch's membrane may have biomechanical properties in terms of strength, the defects found around the macula, added to the major atrophic component, may be a cause of a local relaxation that induce a central bulge forming the dome.

Inner limiting membrane bridges within Bruch's membrane defects in pathological myopia

AbstractPurpose: To examine peculiarities of the inner limiting membrane (ILM) in axially elongated eyes.Methods: The histomorphometric study included human globes enucleated due to reasons such as painful secondary angle‐closure glaucoma or malignant uveal melanomas. Using light microscopy, we searched for regions with ILM‐specific features in association with a marked axial elongation.Results: Out of 279 eyes (279 patients) (mean age: 61.8 ± 13.9 years; axial length: 25.5 ± 3.1 mm (range: 20.0–37.0 mm)), two eyes (axial length: 30 mm and 34 mm, respectively) showed one region and two regions, respectively, characterized by ILM presence and absence of all other retinal layers, retinal pigment epithelium, Bruch's membrane (BM) and choroid. The length of these regions, called ILM‐bridges, was 1.06, 0.73, and 0.62 mm, respectively. All ILM‐bridges were spatially associated with a larger, underlying BM defect and with localized scleral thinning without a staphylomatous scleral configuration. The distance between the ILM‐bridges and the optic disc ranged between 1.92 and 4.21 mm. In univariable analysis, ILM‐bridge number increased with longer axial length (beta: 0.19; p = 0.002) and higher BM defect prevalence (beta: 0.21; p = 0.001), while in multivariable analysis, the ILM‐bridges number remained to be significantly correlated with a higher prevalence of BM defect (beta: 0.15; p = 0.048).Conclusions: ILM‐bridges are a hallmark of pathologic myopia and occur in spatial association with underlying, larger BM defects. ILM‐bridges may be due to a local stretching and rupture of all other retinal layers, caused by the BM defect‐related enlargement of the retinal underground, with the ILM as a basal membrane presenting the highest resistance against the stretching‐associated biomechanical force.

PREVALENCE AND CHARACTERISTICS OF MULTIFOCAL CHOROIDITIS/PUNCTATE INNER CHOROIDOPATHY IN PATHOLOGIC MYOPIA EYES WITH PATCHY ATROPHY.

To determine the prevalence and characteristics of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) in eyes with patchy atrophy because of pathologic myopia. Five hundred eyes of 253 patients with patchy atrophy were examined between 2014 and 2020 at the Advanced Clinical Center for Myopia. The main outcome measures included the prevalence and characteristics of active MFC/PIC lesions diagnosed by optical coherence tomography. Fifty-five of the 500 eyes (11%) diagnosed with patchy atrophy had optical coherence tomography features of active MFC/PIC lesions, such as focal elevations of the retinal pigment epithelium filled with medium hyperreflectivity material, curvilinear scars (Schlaegel lines), and/or areas of outer retinal atrophy. At the time when the MFC/PIC was diagnosed, the mean age was 57.3 ± 12.0 years, and the mean axial length was 29.2 ± 1.8 mm. Macular neovascularization was found in 45 of eyes (81.8%) with MFC/PIC versus 151 eyes without such findings (33.9%; P < 0.001). In 25 of the 55 eyes (45.5%), active MFC/PIC lesions were found before the development of the patchy atrophy. The Bruch membrane defects were colocated with these lesions. Active MFC/PIC lesions were identified in a minority of eyes with pathologic myopia, and a subset of these lesions were observed to progress to findings indistinguishable from myopic patchy atrophy. Evidence of MFC/PIC in eyes with pathologic myopia appeared to be a risk factor for the development of macular neovascularization.

Macular Bruch's membrane defects and other myopic lesions in high myopia.

To compare the ocular fundus features of highly myopic eyes with and without macular Bruch's membrane (BM) defects and investigate the associations between macular BM defects and other myopic lesions. This retrospective, observational case series included 262 eyes (139 patients) with high myopia (HM) refractive error ≥-6.0 diopters (D) or axial length ≥26.5 mm from March 2019 to December 2019. The patients underwent a comprehensive ophthalmic examination, including swept-source optical coherence tomography (SS-OCT). The features of macular BM defects and other ocular fundus lesions were examined in OCT images. Totally 51 eyes (19.5%) were detected with macular BM defects, which were characterized by a lack of BM, retinal pigment epithelium (RPE), and an almost complete loss of photoreceptors or choriocapillaris. Eyes with macular BM defects had worse best-corrected visual acuity (BCVA) than those without (P<0.001). Dome-shaped macula (DSM, P=0.042), retinal cysts (P=0.006), choroidal neovascularization (CNV, P<0.001), choroidal defects and abnormality (P=0.003), scleral defects (P=0.015), scleral deformation (P=0.005), posterior staphyloma (P=0.011), and perforating vessels (P<0.001) occurred more frequently in eyes with macular BM defects. In multivariate analysis, the presence of macular BM defects remained the significant association with presence of DSM (P=0.013), scleral defects (P=0.015), posterior staphyloma (P=0.001), perforating vessels (P<0.001) and CNV (P=0.004). Macular BM defects has a prevalence of approximately 20% in HM and it has tight association with other myopic fundus lesions. BM might be crucial in the pathogenesis of myopic fundus lesions due to its biomechanical function. A comprehensive understanding of BM's role is useful for further researches about myopic lesions.

Parapapillary gamma zone enlargement in a 10-year follow-up: the Beijing Eye Study 2001-2011.

To assess prevalence and associated factors of parapapillary gamma zone enlargement (GZE). Using fundus photographs and optical coherence tomographic images of participants of the population-based Beijing Eye Study, we examined gamma zone changes in a 10-year follow-up. The study included 89 highly myopic eyes (61 participants; age: 65.0 ± 9.8 years) and 86 randomly selected non-highly myopic eyes. GZE prevalence was significantly higher in highly myopic eyes than non-highly myopic eyes (75/89; 84%; 95% CI: 77, 92 versus 18/86; 21%; 95% CI:12, 30; p < 0.001). None of the eyes showed a reduction in gamma zone size. Higher prevalence of segmental GZE without enlargement of Bruch's membrane opening (BMO) (mean: 26/175; 14.9%; 95% CI: 9.5, 20.2) was associated with optic disc size reduction (OR: 43.3; 95% CI: 10.9, 172; p < 0.001), disc-fovea distance elongation (OR: 15.4; 95% CI: 3.12, 76.4; p = 0.001) and lower prevalence of high axial myopia (OR: 0.08; 95% CI: 0.01, 0.44; p = 0.001). Higher prevalence of circular GZE (mean: 38/175; 21.7%; 95% CI: 16, 28) was correlated with optic disc enlargement (OR: 4.30; 95% CI: 1.58, 11.7; p = 0.004), and higher prevalence of myopic maculopathy progression (OR: 4.04; 95% CI: 1.60, 10.2; p = 0.003), or alternatively, higher prevalence of high myopia (OR: 4.44; 95% CI: 1.76, 11.2; p = 0.002). Circular GZE or BMO enlargement was associated with lower prevalence of macular BM defect enlargement (p = 0.035). GZE occurred perpendicular to the orientation of myopic lacquer cracks in 12 out of 17 (71%; 95% CI: 46, 95) eyes with lacquer cracks. Segmental GZE occurred in 49 (89%) out of 55 eyes in the same direction as shortening of the disc diameter developed. The observations support the possibility of a posterior myopic axial elongation-associated BMO shift, leading to a segmental GZE in non-highly myopic eyes, followed by a circular GZE in highly myopic eyes. Large gamma zone might be protective against macular Bruch's membrane defects.

Automatic Screening and Identifying Myopic Maculopathy on Optical Coherence Tomography Images Using Deep Learning.

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.

Evolution of Macular Bruch Membrane Defects of Patchy Chorioretinal Atrophy in Pathologic Myopia Based on a Recent Classification System

Purpose: The purpose of this study was to analyze the progression of macular Bruch membrane defects (BMD) in highly myopic patients with patchy atrophy (PA); and study its correlation with the enlargement of PA and ATN grading. Setting/Venue: Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain. Patients and Methods: This was a cross-sectional, noninterventional study. A series of 451 highly myopic eyes with spherical equivalent > −6.0 D and/or >26 mm of axial length (AL) were included. All patients underwent a complete ophthalmological examination and swept-source optical coherence tomography (SS-OCT), and were graded using the ATN system by 2 masked retina experts that assessed the atrophic (A), tractional (T), and neovascular (N) components. SS-OCT b-scans were employed to study PA and macular BMD at baseline and at a 1-year follow-up, in patients with good foveal fixation. Results: Out of total 451 eyes, 126 eyes (27.9%) had PA (53 patients; 75.4% women). Mean T and N in eyes with PA were 1.1 ± 1.3 and 0.08 ± 0.2, respectively. Sixty-eight of them had >1-year follow-up with a good foveal fixation and enough image quality. From them, BMD were found in 44 eyes (64.7%) at baseline and increased to 59 eyes (86.7%) at a 1-year follow-up. The mean great linear dimension of PA and macular BMD increased with a median of 384.5 ± 462.5 μm (IR 68.0–660.2) and 265.6 ± 418.1 μm (IR 0–331.7), respectively. At 1-year, PA and BMD sizes increase, and were statistically significant (p < 0.001). There was a positive correlation between the growth of macular BMD and the growth of PA (r = 0.490, p < 0.00). T grading correlated significantly with PA growth (p < 0.05). Conclusions: Macular BMD increase its prevalence and its size over time in highly myopic patients with PA. There is a positive correlation between BMD and PA area growth. New studies with a larger sample size, longer follow-up, and AL elongation correlation are necessary to corroborate our findings.

Choroidal neovascularization secondary to pathological myopia-macular Bruch membrane defects as prognostic factor to anti-VEGF treatment.

To evaluate the prevalence and visual outcomes of macular Bruch membrane (BM) defects in patients treated with anti-vascular endothelial growth factors (VEGF) for choroidal neovascularization secondary to pathological myopia (mCNV). Single-center retrospective observational case series of 68 eyes from 62 patients with mCNV treated with one anti-VEGF injection followed by a pro re nata (1 + PRN) regimen. A minimum follow-up of 6 months was defined. Chorioretinal atrophy was assessed by fundus examination, fluorescein angiography, and SD-OCT. Median follow-up was 28.5 (range 6-89) months with a median number of 5 anti-VEGF injections. At baseline, 27.9% of eyes had macular BM defects increasing to 36.8% during follow-up (p<0.001). Eyes without macular BM defects at the baseline had higher BCVA at the last observation than patients with BM defects (p=0.003). An increase of 5 or more ETDRS letters was more frequent in eyes without BM defects (p=0.001). At the end of follow-up, mCNV-related macular atrophy was present in 44.1%; out of which, 83.3% presented macular BM defects (p<0.001). Eyes with mCNV-related macular atrophy without BM defects had a significant increase of best-corrected visual acuity compared with eyes with mCNV-related macular atrophy and BM defect (p=0.002). Macular Bruch membrane defects are often seen in mCNV and have a significant impact in visual acuity and prognosis. Eyes with macular BM defects have a poorer response and worse visual outcomes after anti-VEGF therapy.

Clinical Characteristics of Highly Myopic Patients With Asymmetric Myopic Atrophic Maculopathy-Analysis Using Multimodal Imaging.

PurposeTo evaluate the factors associated with asymmetric myopic atrophic maculopathy (MAM) in highly myopic patients.MethodsWe enrolled highly myopic patients with asymmetric MAM according to the atrophy, traction, and neovascularization (ATN) classification. The results of color fundus photography, optical coherence tomography (OCT), OCT angiography, and corneal visualization Scheimpflug technology (Corvis ST tonometry) were reviewed. The association between inter-eye differences in clinical features and MAM grading was analyzed using logistic regression analysis.ResultsAmong the 72 eyes of 36 patients 61.0 ± 9.3 years of age, 9, 33, 17, and 13 eyes had A1, A2, A3, and A4, respectively. The mean axial length was 30.44 ± 1.92 mm, and there was no significant difference between eyes with less severe and more severe MAM. The inter-eye differences in MAM grading were associated with the inter-eye differences in the presence of Bruch's membrane defects (P = 0.014), ellipsoid zone disruption (P = 0.013), vessel density of the deep retinal layer (P = 0.022), foveal avascular zone circularity (P = 0.012), foveal avascular zone area (P = 0.049), flow area of the choriocapillaris (P = 0.013), vessel diameter (P = 0.045), and fractal dimension (P = 0.015). No Corvis ST parameter was statistically significant. A higher difference in the choriocapillaris flow area (P = 0.013; adjusted odds ratio = 1.10 [1.02–1.18]) remained associated with higher inter-eye differences in MAM grading in the multivariable regression.ConclusionsA smaller choriocapillaris flow area was associated with more severe MAM, suggesting that vascular factors play pivotal roles in MAM.

Morphological differences between two types of Bruch's membrane defects in pathologic myopia.

To investigate morphological differences between two types of Bruch's membrane (BM) defects-patchy atrophy (PA) and CNV-related macular atrophy (CNV-MA) METHODS: Eyes presenting with PA or CNV-MA were included. Scleral thickness (ST), choroidal thickness (CT), and scleral morphological characteristics were obtained by swept-source optical coherence tomography (SS-OCT). Fundus photographs were performed to measure the size of PA and CNV-MA lesions. Among a total of 167 eyes evaluated, 106 eyes had PA and 61 eyes had CNV-MA. In addition, dome-shaped macula (DSM) was identified in 20 (18.87%) and 10 (16.39%) eyes among PA and CNV-MA, respectively. The eyes of CNV-MA without DSM showed a thicker subfoveal ST (278.61 ± 56.17 vs 231.58 ± 66.09 mm, P < 0.001), a thinner subfoveal CT, and a higher rate of scleral perforating vessels (70.6% vs 50.0%, P = 0.021) when compared with those of PA without DSM. The size of PA/CNV-MA lesions was associated with CT in eyes without DSM. However, it was only associated with bulge height in eyes with DSM (r = 0.5, P = 0.013). The eyes with CNV-MA had a thicker sclera than those with PA, which add another evidence to indicate the absence of the progressive relationship between two types of BM defects. The enlargement of lesions in BM defects between eyes with and without DSM may be caused by different mechanical forces. SS-OCT, which focuses on scleral and choroid morphology, may be necessary for more accurate classification of pathologic myopia.

ABRUPTLY EMERGING VESSELS IN EYES WITH MYOPIC PATCHY CHORIORETINAL ATROPHY.

To determine the prevalence and characteristics of abruptly emerging vessels (AEVs) within patchy atrophy (PA) in myopic eyes. We studied 160 highly myopic eyes of 144 patients between March and November in 2016. Fundus photographs and swept-source optical coherence tomography images were analyzed. Patient mean age was 67.1 ± 10.5 years. Mean axial length was 30.9 ± 2.0 mm. The mean size of the 264 PAs was 5.6 ± 8.3 mm. Abruptly emerging vessels were detected in 69 (43.1%) eyes and were located within or near PA edge in fundus photographs. Swept-source optical coherence tomography showed that the AEVs were continuous with perforating scleral vessels and were observed on the inner surface of the sclera at the site where they appeared in fundus photographs. A slight bowing of sclera around the AEVs was observed in 41 (59%) eyes. Patchy atrophy with AEVs was significantly larger (10.7 ± 11.3 mm) than PA without AEVs (3.4 ± 5.1 mm). Abruptly emerging vessels are commonly found in eyes with myopic PA. The sclera surrounding the AEVs is slightly bowed. Further studies are needed to determine whether the penetrating site of AEVs is structurally more fragile and leads to Bruch membrane defects or AEVs are secondarily involved during PA progression.

CLINICAL FEATURES OF PATCHY CHORIORETINAL ATROPHY IN PATHOLOGIC MYOPIA.

To reveal clinical features of patchy atrophy in pathologic myopia and investigate the status of the Bruch membrane and retinal pigment epithelium by swept-source optical coherence tomography. This study reviewed highly myopic patients who visited the high myopia clinic between January 2015 and February 2018. Wide-field photographs and wide-field fundus autofluorescence fundus images were used as the primary method for identifying PAs, and swept-source optical coherence tomography images were used for investigating the retinochoroid status of PAs. Four hundred fifty-six PAs were detected in 137 eyes (118 patients). Patchy atrophys were located most often in the macular area (28.3%), followed by the inferior (25.9%), temporal (18.9%), nasal (14.5%), and superior (12.5%) region. All 210, PAs which had been fully or partially scanned by swept-source optical coherence tomography, showed a retinal pigment epithelium defect, and 174 (82.9%) PAs showed a Bruch membrane defect on the available scans. In 101 (82.8%) of 122 PAs with clearly detectable borders of the retinal pigment epithelium and Bruch membrane defect, the Bruch membrane defects were smaller than the retinal pigment epithelium defects. A dome-shape inward bulging of the sclera was observed in 10 PAs. These morphological findings may provide a basis for exploring the biomechanical etiology of the PAs as part of the development of pathologic myopia.

Histology of myopic posterior scleral staphylomas.

Since histomorphometric descriptions of posterior scleral staphylomas, although forming a major part of myopic maculopathy, have been scarce so far, we histomorphometrically examined scleral staphylomas in enucleated human eyes. Using light microscopy, we histomorphometrically examined sagittal histological sections of human globes enucleated due to malignant choroidal melanomas or secondary angle-closure glaucoma. Out of 246 globes included into the study, posterior scleral staphylomas were detected in 10 eyes (mean length: 31.4±3.0mm; range: 28.0-37.0mm). In the staphylomatous region in the study group as compared with the corresponding region of a control group adjusted for age and axial length, scleral thickness was significantly lower (109±25µm versus 319±161µm; p=0.001). The study group in the staphylomatous region as compared to the highly myopic control group in the corresponding region did not differ significantly in retinal pigment epithelium (RPE) cell density (19.6±4.9 cells/300µm versus 21.1±5.7 cells/300µm; p=0.84) and RPE height (8.2±2.8µm versus 6.1±2.5µm; p=0.13), Bruch's membrane (BM) thickness (3.5±1.3µm versus 4.2±2.3µm; p=0.40) and choriocapillaris thickness (5.3±2.8µm versus 4.4±2.8µm; p=0.49) and density (164±99µm versus 226±38µm; p=0.13). All staphylomatous regions showed a localized BM defect. Marked scleral thinning and spatially correlated BM defects histologically characterized myopic scleral staphylomas, while thickness and density of the choriocapillaris and RPE and BM thickness did not differ significantly between staphylomatous versus non-staphylomatous eyes in the respective regions. These findings support the notion that a locally reduced scleral resistance against a backward pushing BM led to a local scleral outpouching. The outpouching-associated increase in curvature length may stretch BM with the sequel of a localized BM rupture.

RIDGE-SHAPED MACULA IN YOUNG MYOPIC PATIENTS AND ITS DIFFERENTIATION FROM TYPICAL DOME-SHAPED MACULA IN ELDERLY MYOPIC PATIENTS.

To assess and compare clinical features of a ridge-shaped macula (defined as macular elevation only in one meridian across the fovea) in individuals younger than 20 years with those of a dome-shaped macula (DSM) in patients aged 20+ years. The retrospective observational case series study included 185 highly myopic eyes of 100 consecutive patients younger than 20 years, who were compared with highly myopic patients with DSMs, aged 20+ years and examined in previous studies. Seventeen (9.2%) eyes of the highly myopic young patients showed macular elevations all of which ran only in the horizontal direction across the vertical optical coherence tomographic section fulfilled the definition of a ridge and did not show any staphylomas or any macular Bruch membrane defects. By contrast, in the older patients with DSMs, the DSMs were significantly higher and had a narrower base than the ridges in the young patients, and showed macular Bruch membrane defects in their vicinity, with the axial length being significantly longer, the myopic maculopathy more severe, and the subfoveal choroid thinner. Macular elevations detected in children and adolescents are usually ridge-shaped maculas and do not have the characteristics of DSMs. In comparison with DSMs, ridge-shaped maculas do not show a spatial association with macular Bruch membrane defects or posterior staphylomas and have a wider basis and smoother elevation slope. As a hypothesis, ridge-shaped maculas may be due to a folding of Bruch membrane at the posterior pole, potentially caused by an asymmetrical enlargement of Bruch membrane in the equatorial region.