Abstract
Purpose
To describe the prevalence, clinical characteristics, associations, and visual outcomes of myopic traction maculopathy (MTM), which was defined by the presence of retinoschisis (RS), macular holes (MHs), or foveal retinal detachment (RD), in an adult high myope cohort in Changsha, China.
Design
A cross-sectional study.
Participants
Chinese adults with high myopia (defined as spherical equivalent [SE] less than or equal to −5 diopters [D]) in the Aier-Singapore Eye Research Institute High Myopia Adult Cohort Study, which is a prospective population-based study.
Methods
Swept-source OCT was performed to detect RS, MH, and foveal RD. Multivariable generalized estimating equation analyses were performed to assess associations of MTM and the impact of MTM on best-corrected visual acuity (BCVA).
Main Outcome Measures
Prevalence, clinical characteristics, associations, and visual outcomes of MTM.
Results
Of 437 participants (839 eyes), MTM was observed in 20 participants with a prevalence of 4.6% (by participants) or in 24 eyes (with a prevalence of 2.9%; by eyes). Overall, the whole cohort (64.7% female) had a mean age of 42.9 ± 7.2 years, an SE of −9.5 ± 4.4 D, and an axial length (AL) of 27.3 ± 1.9 mm. Retinoschisis was the most common lesion (91.7%; 22/24 eyes with MTM). In the multivariable analysis, the prevalence of MTM was associated with a more myopic SE (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.01–1.18; P = 0.03), longer AL (OR: 1.30; 95% CI: 1.03–1.65; P = 0.03), myopic macular degeneration (MMD) (OR: 12.77; 95% CI: 3.18–51.24; P < 0.001), and older age (OR: 1.06; 95% CI: 1.01–1.11; P = 0.01). In the multivariable analysis, the prevalence of MTM was also associated with poorer BCVA (beta coefficient: −0.07; 95% CI: −0.13 to −0.01; P < 0.01).
Conclusions
The prevalence of MTM was 4.6% in an adult high myope cohort. Associations with MTM include more myopic SE, longer AL, MMD, and older age. Myopic traction maculopathy is associated with poorer vision.
Financial Disclosure(s)
The authors have no proprietary or commercial interest in any materials discussed in this article.
Keywords: Myopic traction maculopathy, Age, Axial length, Spherical equivalent, Myopic macular degeneration
Pathologic myopia (PM) is a significant public health issue1,2 and is projected to become a leading cause of vision loss globally.3, 4, 5, 6, 7, 8 Myopic traction maculopathy (MTM), which arises from tractional forces exerted on the macula, is one of the most severe complications of PM and poses a threat to vision.9, 10, 11, 12 Myopic traction maculopathy has been defined to include retinoschisis (RS), lamellar or full-thickness macular hole (MH), or foveal retinal detachment (RD).13
Previous hospital-based studies have reported that the prevalence of MTM among high myopes was up to 38%.14, 15, 16 East Asia also has the highest incidence of MTM.17 Considering the public health burden, it is important to understand the prevalence of MTM and its clinical characteristics, associations, and visual outcomes. However, many studies are hospital-based studies with selection bias, and only aspects of MTM have been described separately, such as RS or MH. Very few population-based studies have assessed MTM comprehensively.
The Singapore Epidemiology of Eye Diseases-2 (SEED-2) study is one such study that assessed a multiethnic adult population.9 Matsumura et al reported that the prevalence of MTM among high myopes (mean age: 60.1 ± 8.0 years) in the general population was 7.3% (26/355 highly myopic eyes).9 A more myopic spherical equivalent (SE), longer axial length (AL), myopic macular degeneration (MMD), and epiretinal traction were independent risk factors of MTM.9 Myopic traction maculopathy was also associated with poorer best-corrected visual acuity (BCVA).9
The prevalence, characteristics, associations, and visual outcomes of MTM in the general population have not been comprehensively described in Asia, with much variability among high myopes. Variations in findings among studies may have arisen from differences in study design, including participant selection, definitions of MTM, and OCT scanning protocols.
In this study, we aimed to describe the prevalence, clinical characteristics, associations, and visual outcomes of MTM in an adult high myopia population-based cohort in Changsha, central China.
Methods
Study Population
This study uses baseline data from the Aier-Singapore Eye Research Institute High Myopia Adult Cohort Study. This is a 10-year prospective population-based cohort study of Chinese adults with high myopia.18, 19, 20 The detailed methodology has been published separately.18, 19, 20 Participants were recruited from the general population in the city of Changsha, Hunan Province, China, between August 2021 and October 2023. Participation was on a voluntary basis. The central study site is the Aier Eye Hospital in Changsha, Hunan, central China. Participants aged 30 years and older and with high myopia (defined as SE less than or equal to −5 diopters [D]21,22) were included. Participants with significant systemic conditions, ocular pathology such as media opacity (including significant cataracts) affecting image quality, a history of intraocular or refractive surgery, amblyopia, uveitis, glaucoma, or intraocular pressure >21 mmHg were excluded. The study adhered to the ethical principles of the Declaration of Helsinki and received approval from the Aier Eye Hospital Institutional Review Board (approval number: AIER2020IRB05). Written informed consent was obtained from all participants.
OCT
Swept-source OCT (Topcon DRI OCT-1 Triton; Topcon Corp.) of the macula was performed under mesopic lighting conditions and with proper pupil dilation. A macular cube 512 (A-scan) × 256 (B-scan) protocol was performed over a 7.0 mm × 7.0 mm area centered on the fovea. Repeated acquisitions were made to ensure high-quality results.
Other Examinations
The participants underwent a thorough ocular examination. For cycloplegic autorefraction, 1 drop of 0.5% proparacaine was applied, followed by 3 drops of 1% cyclopentolate at 5-minute intervals to induce cycloplegia. Thirty minutes after the final drop, cycloplegic autorefraction was performed using an autorefractor (Nidek ARK-1; Nidek Technologies). Five measurements were made for each eye, with all readings differing by <0.25 D. The average value was used for analysis. Trained optometrists performed subjective BCVA assessments, using logarithm of the minimum angle of resolution. Slit lamp examinations were also carried out.
Spherical equivalent was calculated as the sum of the spherical dioptric power and half of the cylindrical dioptric power. Axial length was measured using the Lenstar LS 900 (Haag-Streit USA), which has a measurement range of up to 32.00 mm. The IOL Master 700 (Carl Zeiss Meditec) was used for ALs >32.00 mm.
A Canon CR-DGi nonmydriatic retinal camera (Canon, Inc.) was used with standardized settings to capture color fundus photographs. The photographs focused on 2 standard areas: ETDRS standard field 1 (centered on the optic disc) and ETDRS standard field 2 (centered on the fovea).
Each participant also completed a self-administered questionnaire to provide information regarding their age, sex, education level (university or below university), and socioeconomic status.
Grading of Retinal Images
Lesions that were examined included RS, lamellar or full-thickness MH, foveal RD, epiretinal membrane (ERM), vitreomacular traction (VMT), internal limiting membrane (ILM) detachment, posterior staphyloma (PS), dome-shaped macula (DSM), and MMD.
Myopic traction maculopathy was defined by the presence of inner or outer RS, lamellar or full-thickness MH, or foveal RD.6,13 Retinoschisis was defined as intraretinal splitting of the layers on OCT images.23 Correspondingly, inner RS involved the inner retina from the retinal nerve fiber layer to the inner nuclear layer, and outer RS involved the outer retina from the outer plexiform layer to the retinal pigment epithelium (RPE).23 Outer RS was further graded based on its location and extent (S0: no RS, S1: extrafoveal region, S2: foveal region, S3: both foveal and extrafoveal, but not the entire macula, S4: entire macula).24 A lamellar MH was defined as an irregular foveal contour with breaks (defects) in the inner fovea but an intact foveal photoreceptor layer.25 A full-thickness MH was defined as an interruption of all foveal retinal layers.26
Epiretinal membrane was defined as an irregular hyperreflective line that is attached to the inner retina.27 Vitreomacular traction was defined as vitreous adhesion to the central macula but no full-thickness tissue dehiscence.28 Accompanying changes included tissue cavitation, cystoid changes in macula, loss of foveal contour, and elevation of fovea above the RPE.28 Posterior staphyloma was defined as an outpouching of a circumscribed portion of the posterior fundus region with a radius of curvature smaller than that of the adjacent zone.29,30 Dome-shaped macula was defined as a significant inward bulge of the RPE of at least 50 μm within the chorioretinal concavity of the posterior pole.31
Myopic macular degeneration was graded using the META-analysis for Pathologic Myopia grading system (category 0: no myopic retinal degenerative lesion; category 1: tessellated fundus; category 2: diffuse chorioretinal atrophy; category 3: patchy chorioretinal atrophy; category 4: macular atrophy).5 An eye had MMD if it demonstrated macular damage of category 2 or worse or a plus lesion.5
A fellowship-trained retina specialist (Q.V.H.) and ophthalmologist (K.-X.C.), who were both masked to the identities of the participants, reviewed and graded all OCT images. The kappa coefficient for intergrader agreement was 0.90.
Statistical Analysis
Statistical analysis was conducted using Stata (version 14.2, StataCorp LLC). Associations between clinical parameters and MTM were assessed using manual stepwise multivariable generalized estimating equation logistic regression models to account for the correlation between both eyes of the same individual.32 Odds ratios (ORs) and their 95% confidence intervals (CIs) were reported. Generalized estimating equation linear regression models were also used to examine the association between MTM and BCVA at distance (presented in decimal form), with beta coefficients and 95% CIs presented. Axial length and SE were collinear and were adjusted separately in multivariable analyses. The threshold for statistical significance was P < 0.05. All P values were 2-tailed.
Results
A total of 437 participants (874 eyes) were examined. After excluding 35 fellow eyes that were not highly myopic (SE greater than −5D), 839 highly myopic eyes were available for analysis. Myopic traction maculopathy was observed in 20 participants with a prevalence of 4.6% per participant, or 24 eyes with 2.9% per eye, with unilateral MTM in 16 participants and bilateral MTM in 4 participants. Table 1 shows the characteristics of the cohort. Overall, the participants had a mean age of 42.9 ± 7.2 years, and 64.7% of the participants were female. The mean SE was −9.5 ± 4.4 D (range: −30.63 D to −5.00 D), and the mean AL was 27.3 ± 1.9 (range: 22.51 mm–34.80 mm). Participants with MTM, compared with those without, were more likely to be older (6.8% with age greater than or equal to median of 41.7 years vs. 2.0% <41.7 years), have a higher refractive error (8.2% with a median SE of less than −8.0 D vs. 0.9% greater than or equal to −8.0 D), have a longer AL (8.8% with a median AL ≥26.9 mm vs. 0.5% <26.9 mm), have MMD (24.3% with MMD vs. 0.8% without MMD), and have received education below the level of university (13.0% below university vs. 3.6% university and above).
Table 1.
Characteristics of the Aier-SERI High Myopia Cohort (n = 437 High Myopes)
| Total (n) | Mean (SD) | Cutoffs | Cutoffs (n) | Presence of MTM |
|||
|---|---|---|---|---|---|---|---|
| MTM (n) | % (95% CI) | P | |||||
| SE (D) | 437 | −9.5 (4.4) | Less than median −8.0 | 218 | 18 | 8.2 (5.3–12.8) | <0.001 |
| Greater than or equal to median −8.0 | 219 | 2 | 0.9 (0.2–3.6) | ||||
| AL (mm) | 437 | 27.3 (1.9) | Less than median 26.9 | 220 | 1 | 0.5 (0.1–3.2) | <0.001 |
| Greater than or equal to median 26.9 | 217 | 19 | 8.8 (5.6–13.3) | ||||
| Age (yr) | 434 | 42.9 (7.2) | Less than median 41.7 | 199 | 4 | 2.0 (0.8–5.3) | 0.02 |
| Greater than or equal to median 41.7 | 235 | 16 | 6.8 (4.2–10.8) | ||||
| Sex | |||||||
| Male | 434 | 153 | 8 | 5.2 (2.6–10.1) | 0.64 | ||
| Female | 281 | 12 | 4.3 (2.4–7.4) | ||||
| Weight (kg) | 345 | 62.0 (11.1) | Less than median 60.0 | 152 | 3 | 2.0 (0.6–6.0) | 0.10 |
| Greater than or equal to median 60.0 | 193 | 11 | 5.7 (3.2–10.0) | ||||
| Height (m) | 345 | 1.6 (0.1) | Less than median 1.6 | 163 | 5 | 3.1 (1.3–7.2) | 0.38 |
| Greater than or equal to median 1.6 | 182 | 9 | 4.9 (2.6–9.3) | ||||
| BMI (kg/m2) | 345 | 23.2 (3.2) | Less than median 23.0 | 171 | 5 | 2.9 (1.2–6.9) | 0.29 |
| Greater than or equal to median 23.0 | 174 | 9 | 5.2 (2.7–9.7) | ||||
| Education level | |||||||
| Below university | 434 | 46 | 6 | 13.0 (5.9–26.4) | 0.004 | ||
| University | 388 | 14 | 3.6 (2.1–6.0) | ||||
| MMD | |||||||
| Absent | 437 | 367 | 3 | 0.8 (0.3–2.5) | <0.001 | ||
| Present | 70 | 17 | 24.3 (15.6–35.8) | ||||
| Age of first glasses (yrs) | 431 | 14.6 (4.9) | Less than median 14.0 | 182 | 8 | 4.4 (2.2–8.6) | 0.85 |
| Greater than or equal to median 14.0 | 249 | 10 | 4.0 (2.2–7.3) | ||||
AL = axial length; BMI = body mass index; CI = confidence interval; D = diopters; MMD = myopic macular degeneration; MTM = myopic traction maculopathy; n = number; SD = standard deviation; SE = spherical equivalent.
Bold values indicate P values < 0.05.
Characteristics and Lesion Frequency of Eyes with MTM
Out of 839 highly myopic eyes, 22 (2.6%) had RS, 4 (0.5%) had an MH (2 lamellar and 2 full-thickness), and 2 (0.2%) had both RS and MH. Retinoschisis was the most common lesion in MTM (91.7%; 22/24 eyes), followed by MH (16.7%; 4/24 eyes). Among the 18 eyes with outer RS, types S1 (extrafoveal) and S3 (both foveal and extrafoveal) were more common (7 eyes [38.9%] each). Type S2 (foveal) (4 eyes [22.72%]) outer RS was less common. Representative color fundus photographs and swept-source OCT images of MTM lesions are shown in Figure 1. Of the 24 eyes with MTM, ERM, VMT, ILM detachment, and PS, they were found in 58.3% (14 eyes), 25.0% (6 eyes), 37.5% (9 eyes), and 91.7% (22 eyes), respectively. One eye (4.2%) had DSM. Also, 83.3% (20 eyes) had MMD. The median BCVA (decimal) was 0.9 (interquartile range: 0.5, 1.0); see Table 2.
Figure 1.
These are representative color fundus photographs and corresponding SS-OCT images of MTM lesions. A, Male; 47.5 years of age. Color fundus photograph of the right eye with an SE of −17.4 D, AL of 30.4 mm, and BCVA at a distance of 1.0 (decimal). The corresponding SS-OCT image shows an S3 outer RS (white asterisk) and vitreomacular traction (white arrow). B, Female; 37.2 years of age. Color fundus photograph of the right eye with an SE of −22.8 D, AL of 31.6 mm, and BCVA at a distance of 0.5 (decimal). The corresponding SS-OCT image shows an inner limiting membrane detachment (white asterisk) and an inner RS (white arrow). There is also a dome-shaped macula (white arrowhead). C, Female; 47.1 years of age. Color fundus photograph of the right eye with an SE of −11.9 D, AL of 28.6 mm, and BCVA at a distance of 1.0 (decimal). The corresponding SS-OCT shows a lamellar macular hole (white asterisk) and an ERM (white arrow). D, Male; 49.9 years of age. Color fundus photograph of the right eye with an SE of −16.1 D, AL of 29.4 mm, and BCVA at a distance of 0.3 (decimal). Corresponding SS-OCT shows a full-thickness macular hole (white asterisk) and an ERM (white arrow). AL = axial length; BCVA = best-corrected visual acuity; D = diopters; ERM = epiretinal membrane; RS = retinoschisis; SE = spherical equivalent; SS-OCT = swept-source OCT.
Table 2.
Characteristics of Eyes with Myopic Traction Maculopathy (n = 20 High Myopes/24 Highly Myopic Eyes)
| Participant | Age (Yrs) | Sex | Eye | SE (D) | AL (mm) | BCVA (Decimal) | Inner RS | Outer RS | MH | ERM | VMT | ILM Detachment | PS | DSM | META-PM Category |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 49.9 | M | OD | −16.1 | 29.4 | 0.3 | × | × | ✓ | ✓ | × | × | ✓ | × | 3 |
| 2 | 46.2 | F | OS | −15.3 | 29.2 | 0.9 | ✓ | S3 | × | × | ✓ | ✓ | ✓ | × | 1 |
| 3 | 75.6 | F | OD | −14.8 | 28.3 | 0.2 | × | S2 | × | × | × | × | ✓ | × | 2 |
| OS | −12.0 | 27.8 | 0.2 | ✓ | S2 | × | × | × | ✓ | ✓ | × | 2 | |||
| 4 | 64.2 | F | OD | −16.9 | 30.7 | 0.4 | ✓ | S3 | × | × | × | × | ✓ | × | 2 |
| 5 | 47.1 | F | OD | −11.9 | 28.6 | 1.0 | × | S2 | ✓ | ✓ | × | × | ✓ | × | 2 |
| 6 | 46.9 | F | OD | −18.4 | 30.9 | 0.9 | × | S1 | × | ✓ | × | × | ✓ | × | 2 |
| 7 | 45.0 | M | OD | −15.6 | 30.2 | 1.0 | × | S1 | × | × | × | × | ✓ | × | 2 |
| 8 | 41.6 | M | OS | −6.4 | 27.8 | 0.4 | ✓ | × | × | ✓ | × | ✓ | ✓ | × | 1 |
| 9 | 42.6 | F | OD | −7.8 | 26.7 | 1.0 | ✓ | S1 | × | × | × | ✓ | × | × | 3 |
| 10 | 41.9 | M | OD | −14.6 | 30.3 | 1.0 | × | S3 | × | × | × | × | ✓ | × | 2 |
| 11 | 50.2 | M | OD | −17.9 | 31.2 | 1.0 | ✓ | S1 | × | ✓ | × | × | ✓ | × | 2 |
| 12 | 37.2 | F | OD | −22.8 | 31.6 | 0.5 | ✓ | × | × | × | × | ✓ | ✓ | ✓ | 3 |
| OS | −18.3 | 29.9 | 1.0 | ✓ | × | × | × | × | ✓ | ✓ | × | 2 | |||
| 13 | 48.7 | M | OD | −23.0 | 33.4 | 1.0 | × | S1 | × | ✓ | × | × | ✓ | × | 3 |
| 14 | 40.4 | F | OS | −17.4 | 29.0 | 0.7 | × | S2 | × | ✓ | ✓ | × | × | × | 2 |
| 15 | 59.6 | F | OD | −23.4 | 31.4 | 1.0 | × | S3 | ✓ | ✓ | × | × | ✓ | × | 3 |
| 16 | 40.6 | F | OS | −10.9 | 28.5 | 0.7 | ✓ | S3 | × | ✓ | × | ✓ | ✓ | × | 1 |
| 17 | 56.6 | M | OD | −23.1 | 33.1 | 1.0 | × | × | ✓ | ✓ | ✓ | × | ✓ | × | 2 |
| OS | −22.4 | 33.1 | 0.1 | × | S1 | × | ✓ | × | × | ✓ | × | 3 | |||
| 18 | 66.9 | F | OS | −14.8 | 29.7 | 0.8 | × | S1 | × | ✓ | ✓ | × | ✓ | × | 3 |
| 19 | 38.9 | F | OS | −14.1 | 30.2 | 1.0 | ✓ | × | × | × | × | ✓ | ✓ | × | 3 |
| 20 | 47.5 | M | OD | −17.4 | 30.4 | 1.0 | × | S3 | × | ✓ | ✓ | × | ✓ | × | 2 |
| OS | −13.5 | 29.0 | 0.6 | ✓ | S3 | × | ✓ | ✓ | ✓ | ✓ | × | 1 |
✓ = present; × = absent; AL = axial length; BCVA = best-corrected visual acuity; D = diopters; DSM = dome-shaped macula; ERM = epiretinal membrane; F = female; ILM = inner limiting membrane; M = male; MH = macular hole; META-PM = META-analysis for Pathologic Myopia; n = number; OD = oculus dexter (right eye); OS = oculus sinister (left eye); PS = posterior staphyloma; RS = retinoschisis; SE = spherical equivalent; VMT = vitreomacular traction.
Ocular and Nonocular Associations with MTM
Table 3 shows the generalized estimating equation logistic regression analyses of ocular and nonocular associations with MTM. In the multivariable analysis, model 1 was adjusted for SE, age, sex, MMD, and education level, and model 2 was adjusted for AL, age, sex, MMD, and education level. In model 1, MTM was associated with a more myopic SE (per 1-D decrement, adjusted OR: 1.09; 95% CI: 1.01–1.18; P = 0.03), older age (per year increment, adjusted OR: 1.06; 95% CI: 1.01–1.11; P = 0.01), and MMD (adjusted OR: 12.77; 95% CI: 3.18–51.24; P < 0.001). Myopic traction maculopathy was also associated with a longer AL (model 2; per 1-mm increment, adjusted OR: 1.30; 95% CI: 1.03–1.65; P = 0.03).
Table 3.
Generalized Estimating Equation Analyses of Ocular and Nonocular Associations with Myopic Traction Maculopathy (n = 839 Highly Myopic Eyes)
| Unadjusted OR (95% CI) | P | Multivariable Model 1∗ OR (95% CI) | P | Multivariable Model 2† OR (95% CI) | P | |
|---|---|---|---|---|---|---|
| SE (D) (per 1-D decrement) | 1.25 (1.18–1.33) | <0.001 | 1.09 (1.01, 1.18) | 0.03 | ||
| AL (mm) (per 1-mm increment) | 1.88 (1.60–2.21) | <0.001 | 1.30 (1.03–1.65) | 0.03 | ||
| Age (yr) (per year increment) | 1.10 (1.06–1.15) | <0.001 | 1.06 (1.01–1.11) | 0.01 | 1.06 (1.02–1.11) | 0.01 |
| Sex | ||||||
| Male | Reference | Reference | Reference | |||
| Female | 0.75 (0.33–1.71) | 0.49 | 1.61 (0.64–4.06) | 0.31 | 1.17 (0.46–2.95) | 0.74 |
| Weight (kg) (per kg increment) | 1.03 (0.99–1.06) | 0.10 | ||||
| Height (m) (per m increment) | 26.64 (0.04–18 635.61) | 0.33 | ||||
| BMI (kg/m2) (per unit increment) | 1.07 (0.98–1.16) | 0.12 | ||||
| Education level | ||||||
| Below university | Reference | Reference | Reference | |||
| University | 0.22 (0.10–0.52) | 0.001 | 0.52 (0.20–1.40) | 0.20 | 0.56 (0.20–1.55) | 0.27 |
| MMD | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | 33.81 (11.33–100.92) | <0.001 | 12.77 (3.18–51.24) | <0.001 | 10.80 (2.26–51.66) | 0.003 |
AL = axial length; BMI = body mass index; CI = confidence interval; D = diopters; MMD = myopic macular degeneration; MTM = myopic macular degeneration; n = number; OR = odds ratio; SE = spherical equivalent.
Bold values indicate P values < 0.05.
Model 1 shows the multivariable association of SE with MTM, adjusted for age, sex, education level, and MMD.
Model 2 shows the multivariable association of AL with MTM, adjusted for age, sex, education level, and MMD.
The respective prevalence of MTM among participants across age (Fig 2A), SE (Fig 2B), and AL groups (Fig 2C) is shown. For age, MTM was observed in participants aged 35 years and older. The prevalence of MTM was 1.3%, 5.6%, and 5.8% in the groups for 30 to <40 years, 40 to <50 years, and 50 to <60 years, respectively. There was a sharp increase in the prevalence of MTM to 27.3% in participants aged ≥60 years.
Figure 2.
This shows the respective prevalence of MTM among the participants across age ranges from 30 years to more than 60 years, SE ranges from −5.00 D to more negative than −20.00 D, and AL ranges from shorter than 26.00 mm to longer than 31.00 mm. A, Myopic traction maculopathy was observed in participants aged 35 years and older. The prevalence of MTM was 1.3%, 5.6%, and 5.8% in the groups for 30 to <40 years, 40 to <50 years, and 50 to <60 years, respectively. There was a sharp increase in the prevalence of MTM to 27.3% in participants of ≥60 years of age. B, Myopic traction maculopathy was present only when SE was −7.5 D or worse, with no cases between −5.00 D and −7.49 D. The prevalence of MTM was 1.6% when the refractive error was between −7.50 D and −9.99 D and 1.9% between −10.00 D and −12.49 D, which increased sharply to 11.1% between −12.50 D and −14.99 D. When SE was −15.00 D or worse, the prevalence of MTM increased even more to between 23.5% and 36.4%. C, Myopic traction maculopathy was observed only in eyes with ALs of 26.00 mm or greater. At ALs between 26.00 mm and 26.99 mm and between 27.00 mm and 27.99 mm, the prevalence of MTM was 0.8% and 1.1%, respectively. Between 28.00 mm and 28.99 mm, the prevalence of MTM increased to 5.3%. For ALs of 29.00 mm or worse, the prevalence increased prominently to between 16.1% and 26.1%. AL = axial length; D = diopters; MTM = myopic traction maculopathy; SE = spherical equivalent.
Myopic traction maculopathy was present only when SE was −7.5 D and worse, with no cases between −5.00 D and −7.49 D. The prevalence of MTM was 1.6% when the refractive error was between −7.50 D and −9.99 D and 1.9% between −10.00 D and −12.49 D, which increased sharply to 11.1% between −12.50 D and −14.99 D. When SE was −15.00 D or worse, the prevalence of MTM increased even more to between 23.5% and 36.4%.
Myopic traction maculopathy was observed only in eyes with ALs of ≥26.00 mm. At ALs between 26.00 mm and 26.99 mm and between 27.00 mm and 27.99 mm, the prevalence of MTM was 0.8% and 1.1%, respectively. Between 28.00 mm and 28.99 mm, the prevalence of MTM increased to 5.3%. For ALs of 29.00 mm or worse, the prevalence increased prominently to between 16.1% and 26.1%.
Visual Impact of MTM
Table 4 shows the generalized estimating equation linear regression analyses of BCVA with MTM and the individual morphological features of inner RS, outer RS, MH, ERM, VMT, ILM detachment, PS, and DSM. In the multivariable analysis, model 1 was adjusted for SE, age, sex, and MMD, and model 2 was adjusted for AL, age, sex, and MMD. Myopic traction maculopathy was associated with poorer BCVA (model 1, β: −0.06; 95% CI: −0.10 to −0.02; P = 0.01; and model 2, β: −0.07; 95% CI: −0.13 to −0.01; P < 0.01). Outer RS (model 1, β: −0.14; 95% CI: −0.22 to −0.06; P < 0.001; and model 2, β: −0.14; 95% CI: −0.23 to −0.06; P = 0.001), ILM detachment (model 1, β: −0.16; 95% CI: −0.25 to −0.08; P < 0.001; and model 2, β: −0.17; 95% CI: −0.26 to −0.08; P < 0.001), PS (model 2, β: −0.07; 95% CI: −0.13 to −0.01; P = 0.03), and DSM (model 2, β: −0.29; 95% CI: −0.55 to −0.02; P = 0.04) were significantly associated with poorer BCVA.
Table 4.
Generalized Estimating Equation Analyses of MTM Association with BCVA at Distance (n = 839 Highly Myopic Eyes)
| BCVA, Decimal |
||||||
|---|---|---|---|---|---|---|
| Unadjusted Beta Coefficient (95% CI) | P | Multivariable Model 1∗ Beta Coefficient (95% CI) | P | Multivariable Model 2† Beta Coefficient (95% CI) | P | |
| MTM | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.22 (−0.28 to −0.15) | <0.001 | −0.06 (−0.10 to −0.02) | 0.01 | −0.07 (−0.13 to −0.01) | <0.01 |
| Inner RS | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.20 (−0.27 to −0.13) | <0.001 | −0.04 (−0.10 to 0.03) | 0.27 | −0.05 (−0.11 to 0.02) | 0.19 |
| Outer RS | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.25 (−0.34 to −0.16) | <0.001 | −0.14 (−0.22 to −0.06) | <0.001 | −0.14 (−0.23 to −0.06) | 0.001 |
| MH | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.12 (−0.28 to 0.03) | 0.12 | −0.10 (−0.23 to 0.04) | 0.15 | −0.07 (−0.21 to 0.07) | 0.31 |
| ERM | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.20 (−0.28 to −0.11) | <0.001 | −0.02 (−0.10 to 0.05) | 0.51 | −0.04 (−0.11 to 0.04) | 0.30 |
| VMT | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.12 (−0.24 to 0.01) | 0.07 | −0.05 (−0.16 to 0.05) | 0.32 | −0.03 (−0.14 to 0.08) | 0.60 |
| ILM Detachment | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.25 (−0.35, to −0.15) | <0.001 | −0.16 (−0.25 to −0.08) | <0.001 | −0.17 (−0.26 to −0.08) | <0.001 |
| PS | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.22 (−0.28 to −0.15) | <0.001 | −0.06 (−0.11 to 0.04 × 10-2) | 0.05 | −0.07 (−0.13 to −0.01) | 0.03 |
| DSM | ||||||
| Absent | Reference | Reference | Reference | |||
| Present | −0.45 (−0.75 to −0.14) | 0.004 | −0.23 (−0.50 to 0.03) | 0.09 | −0.29 (−0.55 to −0.02) | 0.04 |
AL = axial length; BCVA = best-corrected visual acuity; CI = confidence interval; DSM = dome-shaped macula; ERM = epiretinal membrane; ILM = inner limiting membrane; MH = macular hole; MMD = myopic macular degeneration; MTM = myopic traction maculopathy; n = number; PS = posterior staphyloma; RS = retinoschisis; SE = spherical equivalent; VMT = vitreomacular traction.
Bold values indicate P values < 0.05.
Model 1 shows the multivariable association of MTM with distance BCVA, adjusted for age, sex, MMD, and SE.
Model 2 shows the multivariable association of MTM with distance BCVA, adjusted for age, sex, MMD, and AL.
Discussion
In this cohort of adult high myopes, we report that the baseline prevalence of MTM was 4.6% among the participants (or 2.9% among eyes). Myopic traction maculopathy was associated with a more myopic SE and longer AL and was linked with MMD. Older adults were more likely to have MTM. Myopic traction maculopathy was also significantly associated with poorer vision.
In considering the epidemiological significance of the prevalence, characteristics, associations, and visual outcomes of MTM in our study, we noted that SEED-2 is the only comparable population-based study. However, we recognize important differences between the cohorts: SEED-2 included an older population (aged ≥40 years) and was multiethnic, whereas our study cohort is slightly younger and comprised entirely of individuals of Chinese ethnicity. To enable more meaningful comparisons, we performed a separate analysis of the SEED-2 dataset stratified by ethnicity, focusing specifically on the prevalence of MTM among Chinese participants with high myopia.
The prevalence of MTM among high myopes in this study (2.9% among eyes) is slightly lower than that among the Chinese high myopes in SEED-2 (4.4%, 9/207 highly myopic eyes).9 After excluding participants younger than 40 years of age from our study cohort, the prevalence of MTM among eyes was 3.9% (21/540 eyes), which is more comparable to the SEED-2 cohort. This finding suggests a potential age-related component in the development of MTM, which we will discuss further below.
Also, the prevalence of RS (2.6%) and MH (0.5%) in this study is lower than that among the Chinese high myope population in SEED-2 (RS: 3.9%, 8/207 highly myopic eyes; and lamellar MH: 1.4%, 3/207 eyes).9 Again, after excluding participants <40 years of age from our study cohort, the prevalence of RS (3.5%, 19/540 eyes) and MH (0.7%, 4/540 eyes) among eyes became more comparable to the SEED-2 cohort. Pan et al, using data from the Beijing Eye Study, reported that the prevalence of RS was 22.5% (48/213 highly myopic eyes).11 You et al, in a separate analysis of the Beijing Eye study, reported that the prevalence of MH was 1.2% (2/164 highly myopic eyes).12 Although the prevalence in the Beijing Eye Study analyses is higher, it is difficult to compare with these studies because of heterogeneity in study design, including the age of participants and definition of high myopia. The Beijing Eye Study cohort was also older (age ≥50 years), and high myopia was defined as an SE of less than or equal to −6 D.11,12 There may also be other differences in study design, including the OCT machines and scanning protocols, which might have influenced the sensitivity of detecting MTM.
Retinoschisis was the most frequently occurring (>90%), followed by MH (about 17%). This agrees with the data from the Chinese high myopes in SEED-2, where RS was present in 88.9% of eyes with MTM (8/9 eyes) and lamellar MH was present in 33.3% of eyes with MTM (3/9 eyes).9
We described that a more myopic SE and longer AL were associated with MTM. The odds of having MTM were 1.09 times greater for every diopter increase in SE and 1.30 times greater for every mm increase in AL. Also of particular importance are the pivotal thresholds in SE (less than or equal to −15.00 D) and AL (≥29.00 mm), where the prevalence of MTM increased very sharply to around 3 in 10 adults. These associations have been well described.9, 10, 11, 12 Correspondingly, among the Chinese high myopes in SEED-2, a more myopic SE (per 1-D decrement, OR: 1.63, 95% CI: 1.38–1.93, P < 0.001) and a longer AL (OR: 2.9, 95% CI: 1.9–4.9, P < 0.001) were associated with MTM.9 Both associations were adjusted for age, sex, and the presence of MMD.
Furthermore, in our study, the odds of having MTM were up to 12.77 times greater when MMD was present. Among the Chinese high myopes in SEED-2, MMD was associated with MTM (OR: 4.8; 95% CI: 1.2–18.9; P = 0.025), after adjustment for age, sex, and SE.9 Greater refractive error, axial elongation, and chorioretinal atrophy are all closely related factors in MTM because they all contribute to mechanical eyeball stretching and retinal thinning.6 The development of MTM has also been ascribed to the weakness in attachments between the inner retina and sclera in areas with advanced chorioretinal atrophy in MMD.9
We found that MTM may be an age-related complication in PM. Furthermore, the prevalence of MTM increased very sharply after the age of 60 years to approximately 3 in 10 highly myopic adults. These findings agree with the general association between older age and pathologic myopic lesions20,33 but contrast with that reported in SEED-2.9 Separate subanalyses by ethnic groups also showed no association between age and MTM. The Beijing Eye Study also reported associations of an increased age, although this was with RS.11 Thus, the role of age in MTM is still unclear. It has been reported that RS was observed in highly myopic teenagers without severe MMD of META-analysis for Pathologic Myopia categories 3 and 4.34 This may mean that MTM can develop at any age because of tractional forces and axial elongation, although age may exacerbate the changes.
Epiretinal membrane, VMT, and ILM detachment were found in up to half the eyes with MTM in this study. Similarly, after adjusting for age, sex, and SE among the Chinese high myopes in SEED-2, epiretinal traction was associated with MTM (OR: 25.0; 95% CI: 2.5–254.4; P = 0.007).9 How ERM, VMT, and ILM, which exert preretinal tractional forces, are thought to be associated with MTM must be considered simultaneously with PS and DSM.6 In this study, >90% of the eyes with MTM had PS, and almost none had a DSM. It has been hypothesized that a PS may cause RS to develop as the forces resulting from the posterior displacement of the RPE and the choroid exceed the adhesive forces between the retina and RPE.35 Conversely, DSM, which is believed to result from the resistance of a locally thickened sclera to staphylomatous deformation, exerts a macular buckling effect that prevents an RS from developing.36
Myopic traction maculopathy was associated with poorer BCVA at distance. Among the Chinese high myopes in SEED-2, MTM was associated with poorer BCVA as well (β: −0.04; 95% CI: −0.07 to −0.01; P < 0.01).9 This multivariable analysis was adjusted for age, sex, MMD, and SE as well, after converting the logarithm of the minimum angle of resolution measurements to decimal form for comparison with our current study. The loss of vision attributable to MTM in this study was approximately 1 line, and most of the participants with MTM could see relatively well. This may be because our cohort is relatively younger and has fewer pathologies such as MH and RD. Other studies have reported deterioration of BCVA with time in MTM.37,38 Longitudinal prospective studies are thus recommended to explore the influence of MTM on BCVA.
We noted that outer RS, ILM detachment, PS, and DSM were significantly associated with a poorer BCVA. These morphological features may have prognostic values for vision. Regarding outer RS, Wang et al observed that the decrease in BCVA in cases of MTM with RS is primarily due to foveal distortion rather than photoreceptor loss.39 The authors found a correlation between reduced BCVA and both full and outer retinal volumes, despite the ellipsoid zone remaining intact.39 Because Müller cells are essential for maintaining retinal function, the mechanical distortion caused by MTM may impair their function, leading to a decline in BCVA.39 As for ILM detachment, this has been reported to be a risk factor for MTM development and progression because pathological ILMs with increased stiffness exert tangential traction on the retina.40 Correspondingly, vitrectomy and conventional ILM peeling have been used to treat MTM by relieving the tangential traction and improving the retinal compliance in the macula.41
Posterior staphyloma is considered a strong predictor of visual acuity in highly myopic eyes and is also closely associated with more advanced stages of MMD.42 On the other hand, although a DSM is thought to be protective in high myopia by opposing the outward expansion of the PS, the association with poorer BCVA in this study could be due to the presence of other morphological changes, such as RS and RPE changes.43 Macular hole did not exhibit a significant association with BCVA. This could be because of the small numbers; only 4 eyes had an MH, of which only 2 were full-thickness.
Taken together, it is clear that there is a significant public health burden of MTM among high myopes in the general population. It is one of the most important complications in PM. Furthermore, the associations of MTM with age, SE, and AL are also known to increase the risk of MMD. These associations of MTM are also nonlinear; the prevalence of MTM jumped after specific thresholds in age, SE, and AL were crossed. Recognizing and understanding that these associations are nonlinear is important. Given the growing prevalence of PM in Asia and the heightened risk of visual impairment in MTM,17 it is essential for ophthalmologists to evaluate the risk of MTM in individuals of high-risk profiles, particularly older adults with severe myopia.
The strengths of our study include the robust study design, particularly the masked grading of multimodal imaging according to a standardized protocol. There are also limitations. Firstly, the cross-sectional study design precluded causal inferences. Secondly, as all participants were aged ≥30 years, this might not be representative of MTM among younger individuals. Thirdly, the sample size was relatively small. because participation was voluntary and no data were collected from individuals who declined to participate, we were unable to compare participants and nonparticipants. This might have introduced selection bias. Next, high myopia was defined using an SE of less than or equal to −5 D21,22; the participants had a range of AL that did not always correlate perfectly with SE becuase of individual differences in ocular refractive components. We acknowledge that relying solely on SE to define high myopia might have introduced heterogeneity in AL within the study population. Lastly, there might have been intermachine differences in AL measurements between the Lenstar LS 900 and the IOL Master 700, although the impact is likely to be small because the IOL Master 700 was used only for the 13 eyes with ALs of >32.00 mm.44,45
In conclusion, in this cohort of adult high myopes, the prevalence of MTM was 4.6%. The associations with MTM include a more myopic SE, longer AL, MMD, and older age. Myopic traction maculopathy is also associated with poorer vision.
Acknowledgments
The authors would like to thank Mr Tan Chun Wei (Lash), Senior Ophthalmic Photographer, and Ms Serene Soo, Clinical Research Coordinator (Myopia Research Group), of the Singapore Eye Research Institute for coordinating the study.
Manuscript no. XOPS-D-25-00304.
Footnotes
Disclosure(s):
The Article Publishing Charge (APC) for this article was paid by the Singapore Eye Research Institute.
All authors have completed and submitted the ICMJE disclosures form.
The authors have no proprietary or commercial interest in any materials discussed in this article.
HUMAN SUBJECTS: Human subjects were included in this study. The study adhered to the ethical principles of the Declaration of Helsinki and received approval from the Aier Eye Hospital Institutional Review Board (approval number: AIER2020IRB05). Written informed consent was obtained from all participants.
No animal subjects were used in this study.
Author Contributions:
Conception and design: Lamoureux, Hoang, Saw, Lan
Data collection: Cheong, Jiang, Htoon, Pan, Foo, Hu, Chen, Ang, Lamoureux, Hoang, Saw, Lan
Analysis and interpretation: Cheong, Jiang, Htoon, Pan, Foo, Hu, Chen, Ang, Lamoureux, Hoang, Saw, Lan
Obtained funding: N/A
Overall responsibility: Cheong, Jiang, Htoon, Pan, Foo, Hu, Chen, Ang, Lamoureux, Hoang, Saw, Lan
References
- 1.Morgan I.G. What public policies should Be developed to deal with the epidemic of myopia? Optom Vis Sci. 2016;93:1058–1060. doi: 10.1097/OPX.0000000000000980. [DOI] [PubMed] [Google Scholar]
- 2.Morgan I.G., Ohno-Matsui K., Saw S.-M. Myopia. Lancet Lond Engl. 2012;379:1739–1748. doi: 10.1016/S0140-6736(12)60272-4. [DOI] [PubMed] [Google Scholar]
- 3.Holden B.A., Jong M., Davis S., et al. Nearly 1 billion myopes at risk of myopia-related sight-threatening conditions by 2050 - time to act now. Clin Exp Optom. 2015;98:491–493. doi: 10.1111/cxo.12339. [DOI] [PubMed] [Google Scholar]
- 4.Verkicharla P.K., Ohno-Matsui K., Saw S.M. Current and predicted demographics of high myopia and an update of its associated pathological changes. Ophthalmic Physiol Opt. 2015;35:465–475. doi: 10.1111/opo.12238. [DOI] [PubMed] [Google Scholar]
- 5.Ohno-Matsui K., Kawasaki R., Jonas J.B., et al. International photographic classification and grading system for myopic maculopathy. Am J Ophthalmol. 2015;159:877–883.e7. doi: 10.1016/j.ajo.2015.01.022. [DOI] [PubMed] [Google Scholar]
- 6.Cheong K.X., Xu L., Ohno-Matsui K., et al. An evidence-based review of the epidemiology of myopic traction maculopathy. Surv Ophthalmol. 2022;67:1603–1630. doi: 10.1016/j.survophthal.2022.03.007. [DOI] [PubMed] [Google Scholar]
- 7.Klaver C.C., Wolfs R.C., Vingerling J.R., et al. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. 1998;116:653–658. doi: 10.1001/archopht.116.5.653. [DOI] [PubMed] [Google Scholar]
- 8.Pan C.-W., Dirani M., Cheng C.-Y., et al. The age-specific prevalence of myopia in Asia: a meta-analysis. Optom Vis Sci. 2015;92:258–266. doi: 10.1097/OPX.0000000000000516. [DOI] [PubMed] [Google Scholar]
- 9.Matsumura S., Sabanayagam C., Wong C.W., et al. Characteristics of myopic traction maculopathy in myopic Singaporean adults. Br J Ophthalmol. 2021;105:531–537. doi: 10.1136/bjophthalmol-2020-316182. [DOI] [PubMed] [Google Scholar]
- 10.Zheng F., Wong C.-W., Sabanayagam C., et al. Prevalence, risk factors and impact of posterior staphyloma diagnosed from wide-field optical coherence tomography in Singapore adults with high myopia. Acta Ophthalmol (Copenh) 2021;99:e144–e153. doi: 10.1111/aos.14527. [DOI] [PubMed] [Google Scholar]
- 11.Pan Z., Huang Y., Li Z., et al. Prevalence, features, and risk factors of macular retinoschisis in high myopic population: the Beijing eye study 2011. Am J Ophthalmol. 2025;270:227–236. doi: 10.1016/j.ajo.2024.10.003. [DOI] [PubMed] [Google Scholar]
- 12.You Q.S., Peng X.Y., Xu L., et al. Myopic maculopathy imaged by optical coherence tomography: the beijing eye study. Ophthalmology. 2014;121:220–224. doi: 10.1016/j.ophtha.2013.06.013. [DOI] [PubMed] [Google Scholar]
- 13.Panozzo G., Mercanti A. Optical coherence tomography findings in myopic traction maculopathy. Arch Ophthalmol. 2004;122:1455–1460. doi: 10.1001/archopht.122.10.1455. [DOI] [PubMed] [Google Scholar]
- 14.Wakazono T., Yamashiro K., Miyake M., et al. Association between eye shape and myopic traction maculopathy in high myopia. Ophthalmology. 2016;123:919–921. doi: 10.1016/j.ophtha.2015.10.031. [DOI] [PubMed] [Google Scholar]
- 15.Fang D., Zhang Z., Wei Y., et al. The morphological relationship between dome-shaped macula and myopic retinoschisis: a cross-sectional study of 409 highly myopic eyes. Invest Ophthalmol Vis Sci. 2020;61:19. doi: 10.1167/iovs.61.3.19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Parolini B., Palmieri M., Finzi A., et al. The new myopic traction maculopathy staging system. Eur J Ophthalmol. 2021;31:1299–1312. doi: 10.1177/1120672120930590. [DOI] [PubMed] [Google Scholar]
- 17.Zhang H.-D., Zhang L., Han F., et al. Visualized analysis of research on myopic traction maculopathy based on CiteSpace. Int J Ophthalmol. 2023;16:2117–2124. doi: 10.18240/ijo.2023.12.26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Wu L., Foo L.-L., Hu Z., et al. Bruch's membrane opening changes in eyes with myopic macular degeneration: AIER-SERI adult high myopia study. Invest Ophthalmol Vis Sci. 2024;65:36. doi: 10.1167/iovs.65.8.36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Jiang Y., Foo L.-L., Hu Z., et al. Association of macular sensitivity with posterior staphyloma in highly myopic eyes: Aier-SERI high myopia adult cohort study. Ophthalmic Physiol Opt. 2025;45:845–853. doi: 10.1111/opo.13467. [DOI] [PubMed] [Google Scholar]
- 20.Foo L.L., Jiang Y., Hoang Q.V., et al. Prevalence and risk factors of myopic macular degeneration: the Aier-SERI high myopia adult cohort. Br J Ophthalmol. 2025;109:721–726. doi: 10.1136/bjo-2024-326116. [DOI] [PubMed] [Google Scholar]
- 21.World Health Organization The Impact of Myopia and High Myopia. Report of the Joint World Health Organization–Brien Holden Vision Institute Global Scientific Meeting on Myopia. 2015. https://myopiainstitute.org/wp-content/uploads/2020/10/Myopia_report_020517.pdf
- 22.Flitcroft D.I., He M., Jonas J.B., et al. Imi - defining and classifying myopia: a proposed set of standards for clinical and epidemiologic studies. Invest Ophthalmol Vis Sci. 2019;60:M20–M30. doi: 10.1167/iovs.18-25957. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Benhamou N., Massin P., Haouchine B., et al. Macular retinoschisis in highly myopic eyes. Am J Ophthalmol. 2002;133:794–800. doi: 10.1016/s0002-9394(02)01394-6. [DOI] [PubMed] [Google Scholar]
- 24.Shimada N., Tanaka Y., Tokoro T., Ohno-Matsui K. Natural course of myopic traction maculopathy and factors associated with progression or resolution. Am J Ophthalmol. 2013;156:948–957.e1. doi: 10.1016/j.ajo.2013.06.031. [DOI] [PubMed] [Google Scholar]
- 25.Witkin A.J., Ko T.H., Fujimoto J.G., et al. Redefining lamellar holes and the vitreomacular interface: an ultrahigh-resolution optical coherence tomography study. Ophthalmology. 2006;113:388–397. doi: 10.1016/j.ophtha.2005.10.047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Gass J.D.M. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol. 1988;106:629. doi: 10.1001/archopht.1988.01060130683026. [DOI] [PubMed] [Google Scholar]
- 27.Elbendary A.M. Three-dimensional characterization of epiretinal membrane using spectral domain optical coherence tomography. Saudi J Ophthalmol. 2010;24:37–43. doi: 10.1016/j.sjopt.2009.12.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Duker J.S., Kaiser P.K., Binder S., et al. The international vitreomacular traction study group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013;120:2611–2619. doi: 10.1016/j.ophtha.2013.07.042. [DOI] [PubMed] [Google Scholar]
- 29.Spaide R.F. Springer; New York: 2014. Staphyloma: Part 1. Pathologic Myopia. [Google Scholar]
- 30.Ohno-Matsui K., Jonas J.B. Posterior staphyloma in pathologic myopia. Prog Retin Eye Res. 2019;70:99–109. doi: 10.1016/j.preteyeres.2018.12.001. [DOI] [PubMed] [Google Scholar]
- 31.Ohno-Matsui K., Wu P.-C., Yamashiro K., et al. IMI pathologic myopia. Invest Ophthalmol Vis Sci. 2021;62:5. doi: 10.1167/iovs.62.5.5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Fan Q., Teo Y.-Y., Saw S.-M. Application of advanced statistics in ophthalmology. Invest Opthalmology Vis Sci. 2011;52:6059. doi: 10.1167/iovs.10-7108. [DOI] [PubMed] [Google Scholar]
- 33.Wong Y.-L., Sabanayagam C., Ding Y., et al. Prevalence, risk factors, and impact of myopic macular degeneration on visual impairment and functioning among adults in Singapore. Invest Ophthalmol Vis Sci. 2018;59:4603–4613. doi: 10.1167/iovs.18-24032. [DOI] [PubMed] [Google Scholar]
- 34.Sun C.-B., You Y.-S., Liu Z., et al. Myopic macular retinoschisis in teenagers: clinical characteristics and spectral domain optical coherence tomography findings. Sci Rep. 2016;6 doi: 10.1038/srep27952. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Baba T., Ohno-Matsui K., Futagami S., et al. Prevalence and characteristics of foveal retinal detachment without macular hole in high myopia. Am J Ophthalmol. 2003;135:338–342. doi: 10.1016/s0002-9394(02)01937-2. [DOI] [PubMed] [Google Scholar]
- 36.Gaucher D., Haouchine B., Tadayoni R., et al. Long-term follow-up of high myopic foveoschisis: natural course and surgical outcome. Am J Ophthalmol. 2007;143:455–462. doi: 10.1016/j.ajo.2006.10.053. [DOI] [PubMed] [Google Scholar]
- 37.Carlà M.M., Boselli F., Giannuzzi F., et al. Longitudinal progression of myopic maculopathy in A long-term follow-up of A European cohort: imaging features and visual outcomes. Ophthalmol Retina. 2025;9:774–786. doi: 10.1016/j.oret.2025.02.015. [DOI] [PubMed] [Google Scholar]
- 38.Meng J., Chen Y., Cheng K., et al. LONG-TERM progression pattern of myopic tractional maculopathy: outcomes and risk factors. Retina Phila Pa. 2023;43:1189–1197. doi: 10.1097/IAE.0000000000003791. [DOI] [PubMed] [Google Scholar]
- 39.Wang S.-W., Hung K.-C., Tsai C.-Y., et al. Myopic traction maculopathy biomarkers on optical coherence tomography angiography-An overlooked mechanism of visual acuity correction in myopic eyes. Eye Lond Engl. 2019;33:1305–1313. doi: 10.1038/s41433-019-0424-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Fang D., Su J., Chen L., Zhang S. The role of internal limiting membrane as a biomarker in the evolution of myopic traction maculopathy. Front Med. 2021;8 doi: 10.3389/fmed.2021.802626. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Kobayashi H., Kishi S. Vitreous surgery for highly myopic eyes with foveal detachment and retinoschisis. Ophthalmology. 2003;110:1702–1707. doi: 10.1016/S0161-6420(03)00714-0. [DOI] [PubMed] [Google Scholar]
- 42.Flores-Moreno I., Puertas M., Fernández-Jiménez M., et al. Myopic maculopathy progression: insights into posterior staphyloma and macular involvement. Am J Ophthalmol. 2025;270:164–171. doi: 10.1016/j.ajo.2024.09.035. [DOI] [PubMed] [Google Scholar]
- 43.Jain M., Gopal L., Padhi T.R. Dome-shaped maculopathy: a review. Eye. 2021;35:2458–2467. doi: 10.1038/s41433-021-01518-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Song J.S., Yoon D.Y., Hyon J.Y., Jeon H.S. Comparison of ocular biometry and refractive outcomes using IOL master 500, IOL master 700, and lenstar LS900. Korean J Ophthalmol KJO. 2020;34:126–132. doi: 10.3341/kjo.2019.0102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Arriola-Villalobos P., Almendral-Gómez J., Garzón N., et al. Agreement and clinical comparison between a new swept-source optical coherence tomography-based optical biometer and an optical low-coherence reflectometry biometer. Eye Lond Engl. 2017;31:437–442. doi: 10.1038/eye.2016.241. [DOI] [PMC free article] [PubMed] [Google Scholar]