Myopia: Risk Factor for Ocular Morbidity and Permanent Visual Loss

Lecture given at the Philippine Eye Health Summit 2019, Crowne Plaza, August 30, 2019

1. MYOPIA: RISK FACTOR FOR OCULAR MORBIDITY & PERMANENT VISUAL LOSS https://www.medicinatv.com ALVINA PAULINE DY SANTIAGO, MD AUGUST 30, 2019

2. Affiliations & Disclosures No financial interests

3. OBJECTIVES

4. Definition: Myopia spherical equivalent objective refractive error is -0.50 or worse Joint report WHO-BHVI, 2017 https://img.webmd.com

5. MYOPIA AXIAL MYOPIA : Increased axial length CURVATURAL MYOPIA : Increased curvature of cornea or lens INDEX MYOPIA : increase in refractive index of lens seen in nuclear sclerosis MYOPIA DUE TO EXCESSIVE ACCOMMODATION : seen in patients with accommodative spasm https://www.slideshare.net/aryalmanu/myopia-37170766 https://img.ledsmagazine.com

6. Definition: High Myopia High Myopia </= -5.00 Uncorrected acuity 6/172 Worse than blindness threshold of <3/60 (6/120) in better eye Joint report WHO-BHVI, 2017 spherical equivalent objective refractive error is -5.00 or worse </= -6.00 D </= -8.00 D Axial length > 26 mm

7. Definition: Pathologic Myopia (degenerative myopia, malignant myopia) Presence of vision threatening changes in retina Posterior staphyloma High myopia + myopia-related fundus abnormalities such as myopic macular degeneration or glaucoma Joint report WHO-BHVI, 2017 https://webeye.ophth.uiowa.edu

8. MYOPIA and VISUAL ACUITY without correction Degree of myopia Visual acuity -0.50 6/9 to 6/12 -1.00 6/1 -2.00 6/36 -3.00 6/60 -4.00 4/60 -5.00 3/60 -6.00 2/60

9. Causes of Myopia https://www.ahaparenting.com http://www.pointsdevue.com https://s3-ap-southeast-1.amazonaws.com https://ugc.futurelearn.com

10. MYOPIA OCULAR MORBIDITY https://m4.healio.com

11. Consequences of High Myopia https://www.researchgate.net https://imagebank.asrs.org https://www.thelancet.com https://journals.plos.org https://endmyopia.org/

12. Consequences of Myopic Macular Degeneration (MMD) SEED Study (Sg Epidemiology of Eye Diseases Study) 2018 >/= 40 years old (Mean 57 + 9.5) 8716 phakic patients Malays, Indians, Chinese (1:1:1) Myopia: 37.5%, High Myopia ( < -5.0) 6.0% MMD Prevalence: 3.8% overall 7.7% low to moderate myopes 28.7% high myopes MMD increased with degree of myopia and age 1 in 26 phakic adults with MMD in Sg Wong et al 2018 https://www.researchgate.net https://imagebank.asrs.org

13. https://www.eyetrusteyecare.ca

14. https://www.eyetrusteyecare.ca https://www.verywellhealth.com https://www.reviewofophthalmology.com https://www.researchgate.net

15. Myopic Maculopathy or Myopic Macular Degeneration Vision threatening Usually high myopia Diffuse patchy macular atrophy +/- lacquer cracks +/- choroidal neovascularization https://www.researchgate.net

16. Joint report WHO-BHVI, 2017 https://www.verywellhealth.com NORMAL

17. Myopic Macular Degeneration Epidemiological surveys Rapid assessment of avoidable blindness (RAAB), WHO Protocol Consistent use of terminology Accurate data on prevalence of myopia and high myopia vision not improved by pinhole and cannot be attributed to other causes direct ophthalmoscopy worse or equal to -5.0D with retinal changes or, worse or equal to -10.00 D Joint report WHO-BHVI, 2017

18. Joint report WHO-BHVI, 2017

19. Myopia & Glaucoma Population based studies: risk of glaucoma increases with increasing myopia Chen et al 2012 Population Study Relationship with glaucoma Blue Mountain Eye Study Odds ratio 2.3 in low myopia; 3.3 in moderate to high myopia (worse than -3.0 D) Barbados Eye Study (Blacks) Myopia one of several risk factors Beaver Dam Eye Study Myopics 60% more likely to have glaucoma than emmetropes Singapore Malays Eye Study 3x higher risk of POAG if -4.0D or worse Beijing Eye Study -6.0 D risk factor in glaucomatous optic neuropathy https://journals.plos.org

20. https://www.researchgate.net Myopia & Cataract Simple myopia does not appear to predispose to cataract Nuclear sclerosis leads to refractive myopic change High myopia associated with cataract Brown and Hill 1987

21. Myopia & Cataract High myopia (-6D or worse) associated with incident nuclear cataract (Odds ratio [OR] 3.3) Incident posterior subcapsular cataract and myopia any myopia (OR: 2.1), moderate to high myopia (worse than -3.5D: OR 4.4) Use of distance glasses before age 20 (OR 3.0) Incident cataract surgery and myopia any myopia (OR 2.1); moderate myopia (-3.5 to -6.0D: OR 2.0); high myopia (worse than -6.0, OR 3.4) Younan , Mitchell, Cumming et al, Blue Mountains Eye Study 2002 https://www.australia.com

22. Myopia & Cataract More difficult cataract surgery in myopes Less precise IOL calculations More complications: posterior wall collapse Hypotony Chong and Mehta 2016 https://eyeworld-websupport911.netdna-ssl.com

23. Key points There is a myopia epidemic, predicted to affect 50% of population by 2050. WHO prefers to define high myopia as -5.0D or worse (some studies use -6.0D or -8.0D as cutoff) Morbidity from myopia includes amblyopia, strabismus, heavy eye syndrome, myopic macular degeneration, choroidal neovascularization, retinal detachment, glaucoma and cataracts. Pathologic myopia can lead to myopic macular degeneration and choroidal neovascularization that can lead to permanent loss of central vision. High myopes are more prone to retinal detachments. High myopia is associated with glaucoma and cataracts.

24. References 1. The impact of myopia and high myopia: report of the Joint World Health Organization–Brien Holden Vision Institute Global Scientific Meeting on Myopia, University of New South Wales, Sydney, Australia, 16–18 March 2015. Geneva: World Health Organization; 2017. Licence : CC BY-NC-SA 3.0 IGO . © WHO 2017. https://www.who.int/blindness/causes/MyopiaReportforWeb.pdf . Accessed August 26, 2019 2. Holden BA, Fricke TR, Wilson DA et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology 2016; 123 (5), 1036-1042 Licence : CC By-NC-ND. https://www.aaojournal.org/article/S0161-6420(16)00025-7/pdf . Accessed August 26, 2019. 3. Aryal M, Myopia. https://www.slideshare.net/aryalmanu/myopia-37170766 . Accessed August 26, 2019. 4. Tan RJ, Demer JL. Heavy eye syndrome vs sagging eye syndrome in high myopia. J AAPOS 2015; 19 (6): 500-506. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688571/pdf/nihms733942.pdf . Accessed August 26, 2019. 5. Verhoeven VJ, et al. for the Consortium for refractive error and myopia (CREAM). Genome wide meta analyses of multi-ancestry cohorts,identify multiple new susceptibility loci for refractive error and myopia. Nature 2013; Nature Genetics 45: 314-318. 6. Mitchell P, Hourihan F., Sandbach J, et al. The relationship between glaucoma and myopia. The blue mountains eye study. Ophthalmology 1999; 106: 2010-2015. https://www.aaojournal.org/article/S0161-6420(99)90416-5/pdf . Accessed August 26, 2019 7. Chen SJ, Lu P, Zhang WF et al. High Myopia as a risk factor in primary open angle glaucoma. Int J Ophthalmol 2012; 5: 750-753. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530820/pdf/ijo-05-06-750.pdf . Accessed August 26, 2019.

25. References 7. Brown NA, Hill AR. Cataract: the relation between myopia and cataract morphology. Br J Ophthalmol 1987; 71: 405-414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1041188/pdf/brjopthal00616-0002.pdf . Accessed August 26, 2019 8. Kubo E, Kumamoto Y, Tsuzuki S, et al. Axial length, myopia, and the severity of lens opacity at the time of cataract surgery. Arch Ophthalmol 2006; 124: 1586-1590. https://scholar.google.com/scholar_url?url=https://jamanetwork.com/journals/jamaophthalmology/articlepdf/418690/ecs60043_1586_1590.pdf&hl=en&sa=T&oi=ucasa&ct=ufr&ei=JepjXeSCLMGeywTjvYmABA&scisig=AAGBfm3bYtjc_QXgTcnGRHJCo9Z0d9xSOw . Accessed August 26, 2019. 9. Deitz GA, Sweeney AR, Jung HC. Posterior wall collapse in high myopia following cataract surgery. Case Report Ophthalmol 2018; 9: 167-171. https://www.karger.com/Article/Pdf/487077 . Accessed August 26, 2019. 10. Chong E, Mehta J. High myopia and cataract surgery. Current Opinion in Ophthalmology 2016; 27: 45-50. https://journals.lww.com/co-ophthalmology/Abstract/2016/01000/High_myopia_and_cataract_surgery.8.aspx . Accessed August 26, 2019. 11. Younan C, Mitchell P, Cumming RG, et al. Myopia and incident cataract and cataract surgery: The Blue Mountains Eye Study. Invest Ophthalmol Vis Sci 2002; 43: 3625-3632. https://iovs.arvojournals.org/article.aspx?articleid=2162247 . Accessed August 26, 2019. 12. Wong YL, 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: 4604-4613. https://iovs.arvojournals.org/article.aspx?articleid=2702940 . Accessed August 27, 2019.

26. #myopia © AP Santiago 2019 August 30, 2019 Seeing the world through the eyes of a child, Is the purest joy that anyone can experience. -Constance Zimmer https://expertbeacon.com