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. 2025 Aug 21;14(8):33. doi: 10.1167/tvst.14.8.33

Choroidal Thickness Distribution and Its Association With Axial Length and Spherical Equivalent in Schoolchildren Assessed by Wide-Field Swept-Source Optical Coherence Tomography

Takahiro Hiraoka 1, Masato Tamura 2, Yoshikiyo Moriguchi 2, Riku Kuji 2, Toshihiro Mino 2, Masahiro Akiba 2, Yosuke Takahashi 3, Kenichi Yoshino 3, Asaki Suzaki 4, Keiji Sugimoto 4, Tetsuro Oshika 1,✉
PMCID: PMC12372941  PMID: 40838943

Abstract

Purpose

The purpose of this study was to evaluate the distribution of choroidal thickness (ChT) in schoolchildren using wide-field swept-source optical coherence tomography (SS-OCT) and to investigate its association with axial length (AL) and spherical equivalent (SE).

Methods

This prospective study included 176 eyes from 88 healthy Japanese schoolchildren aged 6 to 15 years (mean age = 9.9 ± 2.4 years). Wide-field SS-OCT was used to measure ChT across a 57 degrees × 57 degrees fundus area. After excluding poor-quality images, 169 eyes were included in the final analysis. The ChT distribution was evaluated by dividing the obtained images into a 3 × 3 grid comprising 9 sections. ChT measurements were performed automatically with custom-designed software. ChT values were compared among the nine regions, and correlations with AL and SE were assessed for each grid section. Additionally, the findings in schoolchildren were compared with historical data from adults.

Results

Mean ChT values across the 9 regions ranged from 172 ± 29 µm in the nasal-inferior region to 307 ± 39 µm in the temporal region. The choroid was thicker in the temporal and macular regions and thinner around the optic disc and inferior regions. Significant negative correlations were found between ChT and AL across all regions (R = –0.50 to –0.23, P < 0.05), indicating that longer ALs were associated with thinner choroids. Similarly, significant positive correlations were observed between ChT and SE (R = 0.19 to 0.55, P < 0.05), demonstrating that higher degrees of myopia were associated with thinner choroids. Moreover, ChT in schoolchildren was generally thicker compared to that in adults.

Conclusions

This study provides a detailed analysis of ChT distribution in schoolchildren, revealing regional variability and a generally thicker choroid compared with adults. The significant correlations between ChT, AL, and SE across all regions suggest a potential role for ChT in ocular growth and myopia progression. These findings underscore the need for longitudinal studies to investigate causal relationships between ChT distribution and myopia development.

Translational Relevance

Wide-field choroidal mapping identifies early structural biomarkers for pediatric myopia progression and control.

Keywords: widefield optical coherence tomography (OCT), choroidal thickness (ChT), axial length (AL), myopia, schoolchildren

Introduction

The digitalization of society is accelerating rapidly. With lifestyles increasingly dependent on digital devices, such as smartphones and tablets, prolonged screen time has become inevitable, contributing to a steady rise in myopia cases worldwide. According to a systematic review by Holden et al.,1 the number of the high myopia population, which was 160 million in 2000, is projected to increase 5.8-fold to 940 million by 2050. As myopia progresses to high myopia, excessive axial elongation causes pathological changes in the retina and choroid, significantly elevating the risk of sight-threatening ocular diseases, including macular degeneration, retinal detachment, and glaucoma.2 In response, the World Health Organization (WHO) has highlighted the critical medical and social importance of implementing comprehensive interventions during childhood, a period when myopia progression and axial elongation are most pronounced.3

Effectively suppressing the onset and progression of myopia has emerged as a critical global challenge, with the importance of proactive intervention gaining widespread recognition.4 Various strategies, including increasing outdoor activity, orthokeratology, atropine eye drops, multifocal contact lenses, specially designed spectacles, and red-light therapy, have been widely adopted in clinical practice.4 However, significant knowledge gaps remain regarding the underlying mechanisms through which these interventions achieve their myopia-suppressing effects. Recent studies have consistently highlighted a correlation between changes in the choroid and effective myopia control.5–12

The choroid, primarily composed of blood vessels, is one of the most vascularized tissues in the body, providing approximately 85% of the retina’s blood supply.13 Its primary role is to deliver oxygen and nutrients to the retina, but it also plays a crucial role in regulating ocular temperature (through heat dissipation) and maintaining intraocular pressure. Additionally, evidence suggests that the choroid is involved in refractive processes and accommodation.14,15 The first discovery of choroidal thickness (ChT) changes in response to optical defocus was made in experimental chick models.16 It was observed that the choroid adjusts its thickness to counteract refractive errors: when positive lenses induce myopic defocus (focal point in front of the retina), the choroid thickens, whereas negative lenses causing hyperopic defocus (focal point behind the retina) lead to choroidal thinning.17 Similar adaptive responses have also been observed in humans, reinforcing the choroid’s role as a dynamic structure that responds to visual stimuli.18–20 Furthermore, the choroid is instrumental in scleral remodeling and regulating eye growth by modulating the release and diffusion of growth factors.21 Troilo et al.22 suggest that in the early stages of myopia development, the choroid may function as a barrier to limit the diffusion of growth factors or act as a mechanical buffer to resist scleral stretching. These mechanisms are thought to contribute to controlling axial elongation and slowing myopia progression.

The peripheral refraction theory is now widely regarded as a leading hypothesis for the mechanism underlying myopia progression.23,24 Based on this theory, various optical devices have been developed for myopia control.9,10,25 Specifically, hyperopic defocus in the peripheral (off-axis) region, rather than on-axis refraction, is believed to play a significant role in myopia progression. By addressing and correcting this peripheral hyperopic defocus, it is thought that myopia progression can be effectively suppressed. However, previous research on the choroid has primarily focused on relatively small regions around the fovea and macula (6 × 6 mm2 in the posterior pole), with only limited studies exploring the peripheral choroid. One of the main barriers to such research has been the lack of technology capable of accurately measuring the shape and characteristics of the peripheral choroid. Recent advancements in wide-field swept-source optical coherence tomography (SS-OCT) devices have made it possible to evaluate larger scanning areas. For example, Moon et al.26 successfully assessed the choroid within a 12 × 12 mm2 region using a 100 kilohertz (kHz) SS-OCT angiography (OCTA) system (Plex Elite 9000; Carl Zeiss Meditec). Similarly, Gao et al.27 utilized a 400 kHz SS-OCTA system (BMizar; Beijing, TowardPi Medical Technology) to evaluate a 17 × 17 mm2 region, examining differences in choroidal characteristics among individuals with low, moderate, and high myopia. However, these wide-field assessments have been limited to adult populations, with no studies focusing on children.

To understand the role of the choroid in the onset and progression of myopia, it is essential to evaluate the choroid in school-aged children during their developmental years. Given that the choroid is an extensive tissue extending to the ora serrata, limiting evaluations to the macular region may overlook crucial information. A comprehensive assessment of the entire choroid is therefore necessary. In light of this, we conducted a wide-field imaging study using a prototype 400 kHz SS-OCTA system (Topcon Corp., Japan) to examine the distribution of ChT over a visual angle of 57 degrees × 57 degrees area in schoolchildren. Additionally, we explored its association with axial length (AL) and refractive error.

Methods

Participants

This prospective study was conducted at the Yoshino Eye Clinic using an observational, cross-sectional design. To ensure an unbiased dataset, only healthy volunteers aged 6 to 15 years were recruited from the general pediatric population through a subject recruitment company. Participants were selected without specific demographic restrictions, and the recruitment process aimed to minimize selection bias. In this study, “healthy” was defined as the absence of systemic or ocular diseases, any history of such conditions, and media opacities that could interfere with imaging. No restrictions were placed on best-corrected visual acuity or AL. A total of 176 eyes from 88 pediatric participants were enrolled, with informed consent obtained from all participants or their guardians prior to participation. Comprehensive ophthalmic evaluations were performed, including slit-lamp biomicroscopy, AL measurements using the MYAH system (Topcon Corp., Tokyo, Japan), anterior segment imaging via OCT (CASIA2; Tomey Corp., Nagoya, Japan), and subjective refraction tests. Wide-field OCT scans were acquired after inducing cycloplegia with 2 doses of 1% cyclopentolate hydrochloride (Cyplegin 1% ophthalmic solution; Santen Pharmaceutical Co., Ltd., Osaka, Japan) administered at 10-minute intervals. All measurements were conducted between 10:00 AM and 5:00 PM. Exclusion criteria included individuals unable to provide consent, those with corneal, lenticular, or vitreous opacities that interfered with imaging, individuals with active ocular diseases or a history of ocular surgery, and any participants deemed unsuitable for the study by the supervising clinician due to reasons such as being uncooperative during clinical examinations or diagnostic procedures. The study protocol was approved by the Institutional Review Board of the RiverSide Clinic (Approval Number: RSC-2208RB02) and was conducted in full compliance with the principles outlined in the Declaration of Helsinki.

OCT Measurements

In this study, a high-speed, wide-field SS-OCT prototype system developed by Topcon Corp. (Tokyo, Japan) was used to acquire detailed fundus data. The system featured a wavelength-tunable laser operating at 400,000 A-scans per second within the 1-µm wavelength range, delivering lateral and axial resolutions of approximately 21 µm and 8.8 µm (full-width-at-half-maximum) in tissue, respectively. The depth imaging range extended up to 5.3 mm in tissue. Using this system, a macula-centered three-dimensional OCT volume was captured in just 1.2 seconds, covering an apparent field of view of 68 degrees × 68 degrees with a sampling resolution of 512 × 512 points. To ensure high-quality imaging, axial motion artifacts in the slower scanning direction were corrected using intersections of vertical lines captured immediately after the horizontal raster scan. This correction process involved frame shifting and tilting to optimize cross-correlation at corresponding A-lines. Only images that fell within the 5.3 mm depth imaging range and exhibited no signal loss due to shadowing from the iris or eyelids were included in the analysis.

Choroidal Thickness Distribution Analysis

The ChT was defined as the distance between Bruch's membrane (BM) and choroid-sclera interface (CSI), both were automatically delineated using an edge-detection-based segmentation algorithm (Fig. 1a). Custom-designed software measured the ChT along each A-line. High-resolution imaging, combined with segmentation, enabled precise and reliable ChT assessment.

Figure 1.

Figure 1.

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Example of choroidal thickness (ChT) measurement. (a) Representative OCT B-scan showing Bruch's membrane (BM) and the choroid-sclera interface (CSI), delineated by solid and dashed lines, respectively. (b) OCT projection image of the fundus. (c) ChT distribution map segmented into 3 × 3 grid, dividing the 57 degrees × 57 degrees fundus region into nine sections: tempo-superior, superior, nasal-superior, tempo, macular, optic disc, tempo-inferior, inferior, and nasal-inferior.

Following the approach of Gao et al.,27 we utilized a 3 × 3 grid to divide the 57 degrees × 57 degrees fundus region into 9 sections (comprising 9 square grids: tempo-superior, superior, nasal-superior, tempo, macula, optic disc, tempo-inferior, inferior, and nasal-inferior) for analysis (Figs. 1b, 1c). All images were manually reviewed to ensure accurate placement of the 3 × 3 grid, with the macular fovea positioned centrally and the optic disc aligned within the nasal grid. Each grid contained 19,600 measurement points (140 × 140 points), and the average ChT value within each square grid was used for subsequent analyses. Areas shaded by eyelashes or pupils, as well as areas with an 8 degrees field-of-view around the optic disc, were excluded from averaging.

To account for ocular magnification differences due to AL variation, data were also analyzed using adjusted measurement areas based on Littmann's formula modified by Bennett.28 Specifically, the length t (in millimeters) was calculated as: t = p × 0.01306 × (x – 1.82), where p is the magnification factor of the OCT device (3.45), and x is the AL in millimeters. A 17 × 17 mm2 region was then divided into the same 3 × 3 grid. Corresponding results are presented in Supplementary Figures S1 and S2.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics version 26 (IBM Corp.). The ChT across the nine grids was compared using a 1-way ANOVA with Bonferroni correction for multiple comparisons. The relationships between ChT and AL or spherical equivalent (SE) refractive error in each grid were assessed using Pearson’s correlation test. A P value of < 0.05 was considered statistically significant.

Results

Of the 176 eyes initially enrolled, 7 were excluded due to poor image quality, resulting in a final analysis of 169 eyes from 88 schoolchildren (44 boys and 44 girls), all of whom were Japanese. The mean age of the participants was 9.9 ± 2.4 years (range = 6 to 15 years). The mean SE refractive error was –1.1 ± 1.7 diopters (D; range = –6.75 to 1.25 D), and the mean AL was 23.8 ± 1.2 mm (range = 21.7 to 26.9 mm; see the Table).

Table.

Baseline Characteristics of Participants

Range
Mean ± SD Min Max
Age, y 9.9 ± 2.4 6 15
Spherical equivalent refractive error, D −1.1 ± 1.7 −6.75 1.25
Axial length, mm 23.8 ± 1.2 21.74 26.92
Sex Boys 44, Girls 44
Race All Japanese
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D, diopter; SD, standard deviation.

The mean ChT in each region was as follows: 269 ± 42 µm in the tempo-superior area, 270 ± 51 µm in the superior area, 236 ± 43 µm in the nasal-superior area, 307 ± 39 µm in the tempo area, 298 ± 51 µm in the macula area, 203 ± 41 µm in the optic disc area, 257 ± 42 µm in the tempo-inferior area, 234 ± 43 µm in the inferior area, and 172 ± 29 µm in the nasal-inferior area. Statistically significant differences in ChT were observed between the regions (P < 0.0001, 1-way ANOVA). Figure 2 presents the mean ChT in descending order: tempo, macula, superior, tempo-superior, tempo-inferior, nasal-superior, inferior, optic disc, and nasal-inferior regions. Significant differences were identified between the following pairs (P < 0.0001, Bonferroni multiple comparison test): macula and superior, tempo-inferior and nasal-superior, inferior and optic disc, and optic disc and nasal-inferior.

Figure 2.

Figure 2.

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Mean choroidal thickness (ChT) in each grid. The mean ChT across the grids, ranked in descending order, was as follows: tempo, macula, superior, tempo-superior, tempo-inferior, nasal-superior, inferior, optic disc, and nasal-inferior regions. Significant differences were identified between the following pairs (P < 0.0001, Bonferroni multiple comparison test): macula and superior, tempo-inferior and nasal-superior, inferior and optic disc, and optic disc and nasal-inferior.

The ChT in each region was further analyzed in relation to AL and SE. Significant negative correlations were observed between the ChT and AL across all regions (R = –0.50 to –0.23, P = 0.002 to < 0.0001, Pearson correlation test; Fig. 3). Similarly, significant positive correlations were found between the ChT and SE in all regions (R = 0.19 to 0.55, P = 0.013 to < 0.0001; Fig. 4).

Figure 3.

Figure 3.

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Scatter plots of choroidal thickness (ChT) versus axial length (AL) in each grid. Significant negative correlations were observed between ChT and AL across all regions (R = −0.50 to −0.23, P = 0.002 to < 0.0001, Pearson correlation test).

Figure 4.

Figure 4.

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Scatter plots of choroidal thickness (ChT) versus spherical equivalent (SE) in each grid. Significant positive correlations were found between ChT and SE in all regions (R = 0.19 to 0.55, P = 0.013 to < 0.0001).

For schoolchildren with an SE of –0.75 to +0.75 D, who do not require glasses, the average ChT was 281 ± 37 µm (range = 190 to 367) in the tempo-superior area, 284 ± 45 µm (range = 202 to 394) in the superior area, 242 ± 43 µm (range = 158 to 320) in the nasal-superior area, 318 ± 33 µm (range = 246 to 404) in the tempo area, 311 ± 46 µm (range = 193 to 398) in the macula area, 207 ± 44 µm (range = 117 to 309) in the optic disc area, 270 ± 40 µm (range = 162 to 378) in the tempo-inferior area, 247 ± 39 µm (range = 171 to 347) in the inferior area, and 177 ± 29 µm (range = 126 to 250) in the nasal-inferior area.

Discussion

In this study, we quantitatively evaluated ChT over a wide fundus area spanning a visual angle of 57 degrees × 57 degrees using a 400 kHz wide-field SS-OCTA in schoolchildren. To our knowledge, this is the first attempt to conduct such an extensive ChT assessment in a pediatric population.

Regarding ChT in the macular area, Ruiz-Moreno et al.29 conducted a study using SS-OCT in a population of a similar age (9.6 ± 3.1 years) to ours (9.9 ± 2.4 years). They reported a macular ChT of 285 ± 57 µm (range = 153–399 µm), which aligns closely with our findings (298 ± 51 µm). However, their evaluation was limited to the perimacular region within 2250 µm from the fovea and did not include the peripheral areas beyond that. In contrast, Gao et al.27 focused on adults but assessed ChT across a wide fundus area (17 × 17 mm2 centered on the fovea) comparable to our study and analyzed ChT by dividing the area into nine (3 × 3) grids. Their findings showed that the choroid was thickest in individuals with low myopia, followed by those with moderate myopia, and thinnest in those with high myopia, regardless of the region (both macular and peripheral grids).

Figure 5 compares the ChT results for schoolchildren with low myopia (≧ –3.00 D) in our study with the results for adults with low myopia (≧ –3.00 D) reported by Gao et al.27 Although this comparison is based on average values, it is evident that the choroid is generally thicker in schoolchildren than in adults, particularly in the middle (tempo, macula, and optic disc) and inferior (tempo-inferior, inferior, and nasal-inferior) regions. This observation suggests that the choroid in the middle and lower areas may thin with age, whereas the upper choroid exhibits relatively little change. In other words, the choroid may undergo vertically asymmetric changes as development progresses. However, as this study was cross-sectional, longitudinal studies are necessary to confirm these hypotheses.

Figure 5.

Figure 5.

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Comparison of choroidal thickness (ChT) between schoolchildren and adults with low myopia. (a) The choroid is generally thicker in schoolchildren than in adults, particularly in the middle (tempo, macula, and optic disc) and inferior (tempo-inferior, inferior, and nasal-inferior) regions. (b) A color-coded thickness map for schoolchildren with low myopia. (c) A color-coded thickness map for adults with low myopia.

When comparing the mean ChT across the nine grids, the choroid was thickest in the tempo and macula grids, followed by the superior, tempo-superior, tempo-inferior, nasal-superior, inferior, optic disc, and nasal-inferior grids in schoolchildren. In Gao et al.’s study on adults,27 the choroid was thickest in the macula grid, followed by the superior, tempo-superior, and tempo grids, and then the nasal-superior, tempo-inferior, inferior, and optic disc grids, with the nasal-inferior grid being the thinnest. Although there were slight differences in the order, both schoolchildren and adults exhibited a consistent trend: thicker choroid in the macula, tempo, and superior regions, and thinner choroid around the optic disc and inferior regions.

Ohno-Matsui30 classified posterior staphylomas into 6 categories based on 3-dimensional magnetic resonance imaging of eye shape: type I (wide macular staphyloma), type II (narrow macular staphyloma), type III (peripapillary staphyloma), type IV (nasal staphyloma), type V (inferior staphyloma), and others (staphylomas not classified as types I to V). Notably, whereas peripapillary and inferior staphylomas are included, temporal and superior staphylomas are absent from this classification. Similarly, Curtin's original classification of posterior staphylomas31 did not include temporal or superior staphylomas, suggesting that these regions are less prone to staphyloma formation. Ohno-Matsui30 also reported that type I staphylomas were the most common, accounting for 74% of cases, with 50% of these showing the most pronounced protrusion below the central axis. This finding indicates a tendency for the lower part of the eye to protrude more than the upper part as the staphyloma expands. Although the cause of this increased vulnerability in the inferior region remains unclear, Gao et al.27 observed that choroidal thinning in the inferior regions (temporo-inferior, inferior, and nasal-inferior) was more prominent in highly myopic eyes. In addition, Tanaka et al.32 investigated highly myopic eyes with posterior staphylomas using wide-field OCT and reported a gradual thinning of the choroid toward the staphyloma edge. They suggested that non-uniform choroidal thinning may create significant variations in ChT, potentially contributing to changes in scleral curvature (development of staphylomas). Taken together, these findings suggest that regional differences and localized choroidal thinning may play a crucial role in the development and morphological patterns of posterior staphylomas.

We observed significant relationships between ChT and both AL and SE across all examined areas. Specifically, as the AL increased and the myopia became higher, the choroid became thinner. Whereas this relationship has been well-documented for the macular region,26,33–40 our study extended this correlation to the peripheral regions. An even more intriguing finding is the contrast with previously reported data for adults. Gao et al.27 observed a decreasing trend in ChT with increasing AL across most grids in adults, except in the nasal-superior and optic disc regions. In contrast, our study found consistent relationships across all areas, including the nasal-superior and optic disc regions, in schoolchildren. The reason for this discrepancy remains unclear. One hypothesis is that in younger individuals, the growth of the eyeball is relatively uniform, leading to similar choroidal changes in both the macular and optic disc regions. However, as the eyeball continues to elongate and myopia progresses, asymmetries may increase, resulting in region-specific differences in choroidal changes. In other words, with aging and the progression of myopia, the choroid around the optic disc may undergo more complex changes and lose its association with AL. The exact role of the choroid in regulating eye growth remains speculative and warrants further investigation through longitudinal studies.

Our study has several limitations. First, the comparison with adult data relied on historical datasets. To ensure consistency, it is essential to compare datasets obtained using the same devices and measurement settings for both schoolchildren and adults. Second, this study is cross-sectional in nature, highlighting the need for longitudinal studies to better understand the impact of ChT distribution on ocular growth and myopia progression, as well as to explore the underlying causal relationships.

In conclusion, we measured ChT across a broader fundus area in schoolchildren than previously reported and assessed its distribution by dividing it into nine grids. Our findings showed that the choroid was relatively thicker in the macular, temporal, and superior regions, whereas it was thinner around the optic disc and in the inferior region. Additionally, the choroid appeared to be generally thicker in schoolchildren compared with adults. Significant correlations between ChT and both AL and SE were observed consistently across all grids. The results of this study provide valuable baseline data for future research. Further studies are essential to clarify how regional variations in ChT influence the onset and progression of myopia.

Supplementary Material

Supplement 1
tvst-14-8-33_s001.docx (157.8KB, docx)

Acknowledgments

Supported by the JSPS KAKENHI Grant Number 20K09783.

Author Contributions: T.H. and Y.M., Designed the study; T.H., M.T., Y.M. and T.M., Prepared the manuscript; M.A., Y.M., R.K., and T.M., Prepared the device, and Y.T., K.Y., A.S. and K.S., Collected the clinical data; M.A., Y.S., K.Y. and T.O., Supervised the research.

Disclosure: T. Hiraoka, None; M. Tamura, Topcon Corp. (E); Y. Moriguchi, Topcon Corp. (E); R. Kuji, Topcon Corp. (E); T. Mino, Topcon Corp. (E); M. Akiba, Topcon Corp. (E); Y. Takahashi, None; K. Yoshino, None; A. Suzaki, Menicon Co., Ltd., (E); K. Sugimoto, Menicon Co., Ltd., (E); T. Oshika, Topcon Corp (F)

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