Degenerative Myopia

Chairman:
Prof. Dr. Dipak Kumar Nag
Professor & Head of the Dept.of Retina,NIO& H
Moderator:
Dr.Kausik Chowdhury
Assistant Professor, Dept of Retina, NIO&H

Presenter:
Dr.Jesmin Akter Sristy
DO resident (1st year), NIO&H
 Myopia
• Myopia or shortsightedness is a type of
refractive error in which parallel rays of light
coming from infinity are focused in front of
the retina when accommodation is at rest.
 Etiological classification
• 1.Axial myopia
• 2.Curvatural myopia
• 3.Positional myopia
• 4.Index myopia
• 5.Myopia due to execcesive accommodation
 Clinical varieties of myopia
• 1.Congenital myopia
• 2.Simple or developmental myopia
• 3.Degenerative or pathological myopia
• 4.Acquired or secondary myopia
 Grading of myopia
• American Optometric Association (AOA) has
defined 3grades of myopia
1.Low myopia,when the error is <-3D
2.Moderate myopia,when the error is
between -3 D to -6D
3.High myopia,when the error is >-6D
 What is Degenerative Myopia?
Degenerative myopia is a condition associated
with the axial elongation of the globe with
the associated thinning and stretching of
Retina,Retinal Pigment epithelium(RPE) and
choroid.
 Synonyms:
• Pathological Myopia,
• Progressive Myopia,
• Malignant Myopia,
• High Degree Myopia,
• Magna Myopia
 Characteristic features
• Progressive
• Myopia with degenerative change in fundus
• Refractive error more than -6D
• Axial length:26.5mm or more
• Starts at childhood(5-10years)
• Positive family history
 Causes
-No satisfactory hypothesis
-linked with
A)Heredity: it is considered to be
-AD
-AR
-X-linked recessive inherited disorder.
B)General Growth process:
-lengthening of the posterior segment of globe
during the period of active growth
- ends with the termination of active growth.
 Etiological hypothesis for pathological myopia
• Genetic factors (play major • General growth process
role) (play minor role)

More growth of retina

Stretching of sclera

Increased axial length

Degeneration of choroid
Features of pathological
Degeneration of retina myopia

Degeneration of vitreous
 Risk factors
• Age: Younger or middle age
• Gender: Female
• Social group: children , professional working
adult
• Occupation : Near work indoors(lawyers
,Physician, editors etc)
• Familial inheritance : Genetic
 Clinical picture
• Symptoms:
• A)Defective vision.
• B)Difficulty in distant vision
• C)Floating black opacities in front of eyes
• D)Difficulty in night vision
 Signs:
Anterior segment:
1)Prominent eyeballs,
2)Large cornea,
3)Deep anterior chamber,
4)slightly larger pupil ,reacting sluggishly to light
 Signs(contd.)
• Posterior Segment:
Fundus examination:
1)Pale tessellated fundus:
Due to diffuse attenuation of
the RPE with visibility of
large choroidal vessels
 Signs(contd.)
2)Optic disc crescent:
-Due to pulling away of
choroid and pigment
epithelium,
-usually from temporal
edge of nerve to expose
the sclera
 Sign(contd.)
3)Focal chorioretinal
atrophy:
-Greyish white and ill defined
atrophy
-characterized by patchy
visibility of choroidal vessels
and often sclera
 Sign(contd.)
4)Anomalous optic nerve
head:
-Unusally small,large or
anomalous with a ‘tilted’
conformation,
-peripapillary chorioretinal
atrophy is very common
 Signs(contd.)
5)Lattice degeneration:
• Spindle-shaped areas of
retinal
thinning,commonly
located between the
equator and the posterior
border of vitreous base
• Sclerosed vessels forming
an arborizing network of
white lines is
characteristic
 Signs(contd.)
6)Lacquer cracks:
• It is rupture of RPE-
Bruch membrane-
choriocapillaris complex
• characterized by fine
irregular yellow lines
criss-crossing at the
posterior pole
 Signs(contd.)
7)Subretinal ‘coin’ shaped
haemorrhages:
May develop from lacquer
cracks in the absence of
CNV
 Signs(contd.)
8)A Fuchs spot:
A raised,circular,pigmented
lesion at the macula
developing after a
subretinal haemorrhage
has absorbed
 Signs(contd.)
9)A Staphyloma:
-A peripapillary or macular
ectasia of the posterior
sclera due to focal
thinning and expansion.
-Associations includes
macular hole formation
and ‘dome-shaped
macula’
 Signs(contd.)
10)Peripapillary/
intrachoroidal cavitation:
A small yellowish-orange
peripapillary area typically
inferior to the disc
 Signs(contd.)
11)Vitreous changes:
-Vitreous Liquefaction
(synchysis)
-Vitreous
condensation(syneresis)
-Posterior vitreous
detachment(PVD),appea
ring as Weiss ring
 Signs(contd.)
12)White without
pressure(WWOP)
- Appears as whitish areas in
peripheral retina
- Occurs without scleral
indentation
-Retinal tears can develop
along the posterior border of
WWOP
-Associated with the traction
of PVD
 Ocular association of high myopia
• Retinopathy of prematurity
• Congenital glaucoma
• Ocular albinism
• Lens subluxation
• Coloboma
• Retinal dystrophy
 Systemic association of High myopia
• Down syndrome
• Stickler syndrome
• Marfan Syndrome
• Prematurity
• Noonan Syndrome
• Ehlers-Danlos syndrome
 Complication of Pathological myopia
1)Rhegmatogenous retinal
detachment (RRD)
• Much more common
• Person with -1 to -3D had a
fourfold greater risk of RD.
• For refractive error>-3 D the
risk was tenfold greater
(disease case-control study)
 Pathogenesis
-increased frequency of PVD
-lattice degeneration
-asymptomatic atrophic holes
-myopic macular holes
-giant retinal tear(occasional)
2)CNV:
• macular CNV is one of the most vision
threatening complications.
• Prevalence is 5 to 10% of eyes with high myopia
• Develops from lacquer cracks.
• Prognosis is better in young patient
• Anti-VEGF therapy is generally the treatment of
choice
Myopic CNV
3)Macular foveoschisis:
• May occur with posterior
staphyloma,probably as a result of vitreous
traction.
• Intraretinal splitting occurs in both the outer
and inner layers of the retina, leading to the
formation of cystoid spaces
Macular foveoschisis
• 4)Macular hole:
• Myopic macular hole may occur, but the exact
mechanism is unknown.
• It may occur spontaneously or after mild
trauma .
• may be associated with RRD .
Color fundus photograph OCT
5)Peripapillary detachment:
Yellow orange elevation of the RPE and sensory
retina at the inferior border of the myopic conus
6)Cataract:
posterior subcapsular or early NS
7)Glaucoma:
-POAG,
-Pigmentary glaucoma
8)Amblyopia:
-uncommon
-significant difference in myopia between the
two eyes
9)Dislocation of the lens:
Rare
 Management
• Optical treatment
• Prophylactic Laser photocoagulation
• Low vision aid
• Counseling
 Optical treatment
Correction of Refractive error:
A)Non-surgical;
-Spectacles
-Contact lens
B)Surgical;
-Corneal refractive surgery
-Phakic intra ocular lens
-Clear lens extraction
Spectacles :
• Appropriate concave lens is prescribed , so
that clear image is formed on the retina
• In very high myopia under-correction is
always better
The lenses may be extremely thick and heavy so
small eyeglass frames combined with high index
lenses is use to make the lenses thinner, lighter
Advantage of spectacles correction:
• -Easy
• -Safe
• -Inexpensive
• Disadvantages of high minus glass:
A)Minification of the object
B)Image distortion(Barrel distortion)
due to spherical aberration
C)Reduced peripheral field of vision
D)Cosmetically , eyes appear smaller behind the
glass
• Contact lens:
Advantages:
-less minification of image
-Image distortion can be
eliminated
-Field of vision is increased
-Better cosmesis
• Disadvantages:
-Not tolerated by all patients
-Needs extreme accuracy and hygiene
-Costly
-Corneal problems like infections , abrasion can
occur
 Surgical treatment:
• LASER IN-SITU-KERATOMILEUSIS(LASIK):
-A flap of 130-160microns thickness of anterior
corneal tissue is raised with microkeratome
-After that the mid-stromal tissue is ablated with
Excimer LASER beam leading to flattening of
cornea
-For myopia of more then -12D
 Precautions for LASIK surgery
• Patient must be counselled about realistic
expectation regarding visual outcome.
• Exclude other ocular disease,e.g Cataract,optic
neuropathy,retinal/macular disease,Dry eye
• Measurement of central corneal thickness,IOP.
• Fundus evaluation for any pathology.
• Refractive Lens Exchange:
-clear crystalline lens is extracted and IOL of
appropriate power is implanted
-for myopia of more than -12D or near
• Phakic refractive lens:
-Also called ‘implantable contact lens’
-Special type of IOL is placed in anterior
chamber or posterior chamber , anterior to
natural crystalline lens
-For myopia of more than -8D
 Prophylactic Laser photocoagulation
Indications:-
• History of RD in the fellow eye
• Family history of RD
• Prior to ocular surgeries
• Symptomatic patient
 Low vision aid
• Pathological myopia patients experience an
irreversible and deep loss of vision.
• In such cases, low-vision interventions are
useful to allow patients to continue or to
improve daily living tasks, independency, and
quality of life.
• Many devices and trainings are available to
achieve this goal.e.g. magnifiers,CCTV etc
 Counseling:

• Should be careful for any trauma in eyes.

• Avoid marriage with another high myopic
person.
• Periodic rest during visual task
• Regular follow up
• Immediate consultation with Ophthalmologist
in acute visual dimness ,flashes, floaters.