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Purpose: To characterize structural differences and assess the diagnostic accuracy of optic nerve head (ONH) and macula optical coherence tomography (OCT) parameters to detect glaucoma in eyes with and without high axial myopia., Design: Cross-sectional study., Methods: Three hundred sixty-eight glaucoma and 411 healthy eyes with no axial myopia, 393 glaucoma and 271 healthy eyes with mild axial myopia and 124 glaucoma and 85 healthy eyes with high axial myopia were included. Global and sectoral peripapillary retinal nerve fiber layer thickness (pRNFLT), Bruch's membrane opening minimum rim width (BMO-MRW), ganglion cell inner plexiform layer thickness (GCIPLT), and macula RNFLT (mRNFLT) were compared and the diagnostic accuracy for glaucoma detection was evaluated using the adjusted area under the receiver operating characteristic curve (AUC)., Results: Diagnostic accuracy for ONH and macula parameters to detect glaucoma was generally high and differed by myopia group. For ONH parameters the diagnostic accuracy was highest for global (AUC = 0.95) and inferotemporal (AUC = 0.91) pRNFLT for high myopes and global BMO-MRW for nonmyopes (AUC = 1.0) and mild myopes (AUC = 0.97). For macula parameters, the diagnostic accuracy was higher in high myopes with 6 of the 11 GCIPLT global/sectors having adjusted AUCs > 0.90 compared to nonhigh myopes with no AUCs > 0.90. In all myopia groups, mRNFLT had lower AUCs than GCIPLT., Conclusions: The diagnostic accuracy for pRNFL and GCIPL was high for high axial myopic eyes and shows promise for glaucoma detection in high myopes. Further analysis is needed to determine whether the high diagnostic accuracy can be confirmed in other populations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Prcis: A large disk, a large parapapillary delta zone and a long axial length may be used as screening criteria to detect glaucomatous optic neuropathy in highly myopic eyes., Purpose: To describe aspects for screening of glaucomatous optic neuropathy in dependence of refractive error, under special consideration of high myopia., Methods/results: Studies on the anatomy of the myopic optic nerve head and results of investigations on the relationship between glaucomatous optic neuropathy and axial myopia were included., Conclusions: In the range from hyperopia to moderate myopia, refractive error is not a strong glaucoma risk factor and may not be included in glaucoma screening strategies. Care should be taken, that in moderate myopia, a shift of Bruch´s membrane opening usually into the temporal direction leads to parapapillary gamma zone and a corresponding shortening of the horizontal disk diameter. In these moderately myopic eyes, a secondarily small optic disk with a correspondingly small optic cup should not lead to an overlooking of intrapapillary glaucomatous changes. Prevalence of glaucomatous or glaucoma-like optic nerve atrophy (GOA) steeply increases with longer axial length in highly myopic eyes (cutoff approximately -8 diopters/axial length 26.5 mm), with prevalences higher than 50% in extremely high myopia. Besides longer axial length, morphological parameters associated with GOA in highly myopic eyes are a secondarily enlarged disk and large parapapillary delta zone. Both parameters, together with long axial length, may be used as screening criteria in high myopia for GOA. The latter is characterized by an abnormal neuroretinal rim shape, that is, vessel kinking close to the intrapapillary disk border. Factors associated with nonglaucomatous optic neuropathy are larger gamma zone and longer axial length, potentially due to an axial elongation-related retinal nerve fiber stretching., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare rates of retinal nerve fiber layer change over time in healthy, eyes with nonprogressing glaucoma and eyes with progressing glaucoma using single wide-field (SWF) and optic nerve head (ONH) cube scan optical coherence tomography (OCT) images., Methods: Forty-five eyes of 25 healthy individuals and 263 eyes of 161 glaucoma patients from the Diagnostic Innovations in Glaucoma Study were included. All eyes underwent 24-2 visual field testing and OCT (Spectralis SD-OCT) ONH and macular imaging. SWF images (up to 43° × 28°) were created by stitching together ONH cube scans centered on the optic disc and macular cube scans centered on the fovea. Visual field progression was defined as guided progression analysis likely progression and/or a significant (P < 0.01) mean deviation slope of less than -1.0 dB/year. Mixed effects models were used to compare rates of change. Highly myopic eyes were included., Results: Thirty glaucomatous eyes were classified as progressing. In eyes with glaucoma, mean global rate of change was -1.22 µm/year (P < 0.001) using SWF images and -0.83 µm/year (P = 0.003) using ONH cube scans. Rate of change was significantly greater in eyes with progressing glaucoma compared with eyes with nonprogressing glaucoma (-1.51 µm/year vs. -1.24 µm/year; P = 0.002) using SWF images and was similar using ONH cube scans (P = 0.27)., Conclusions: In this cohort that includes eyes with and without high axial myopia, the mean rate of retinal nerve fiber layer thinning measured using SWF images was faster in eyes with progressing glaucoma than in eyes with nonprogressing glaucoma. Wide-field OCT images including the ONH and macula can be effective for monitoring glaucomatous progression in patients with and without high myopia.

Purpose: The purpose of this study was to examine characteristics of lamina cribrosa (LC) configuration in highly myopic (HM) eyes., Methods: Participants from the Beijing Eye Study 2011, free of optic nerve or retinal diseases, were randomly selected to examine LC depth (LCD) and LC tilt (LCT) using three-dimensional optical coherent tomography images of the optic nerve head (ONH). LCD and LCT were measured as the distance and angle between the LC plane with two reference planes, including the Bruch's membrane opening (BMO) plane and the peripapillary sclera (PPS) plane, respectively. Each parameter was measured in both horizontal and vertical B-scans., Results: The study included 685 individuals (685 eyes) aged 59.6 ± 7.7 years, including 72 HM eyes and 613 non-HM eyes. LCD measurements showed no significant differences between HM eyes and non-HM eyes in both horizontal (LCD-BMO = 421.83 ± 107.86 µm for HM eyes vs. 447.24 ± 104.94 µm for non-HM eyes, P = 0.18; and LCD-PPS = 406.39 ± 127.69 µm vs. 394.00 ± 101.64 µm, P = 1.00) and vertical directions (LCD-BMO = 435.78 ± 101.29 µm vs. 450.97 ± 106.54 µm, P = 0.70; and LCD-PPS = 401.62 ± 109.9 µm vs. 379.85 ± 110.35 µm, P = 0.35). However, the LCT was significantly more negative (tilted) in HM eyes than in non-HM eyes horizontally (LCT-BMO = -4.38 ± 5.94 degrees vs. -0.04 ± 5.86 degrees, P < 0.001; and LCT-PPS = -3.16 ± 5.23 degrees vs. -0.94 ± 4.71 degrees, P = 0.003), but not vertically (P = 1.00)., Conclusions: Although LCD did not differ significantly between HM and non-HM eyes, LCT was more negative in HM eyes, suggesting that the temporal or inferior side of the LC was closer to the reference plane. These findings provide insights into morphological and structural changes in the LC and ONH between HM and non-HM eyes.

Purpose: To describe the occurrence, morphology and associations of parapapillary drusen of the retinal pigment epithelium (RPE-drusen)., Methods: Using light microscopy, we histomorphometrically examined enucleated human eyes., Results: The study included 83 eyes (axial length: 25.9 ± 3.2 mm; range: 20.0-35.0 mm). Eyes with parapapillary RPE-drusen (n = 29 (35%) eyes) as compared to those without drusen had a significantly shorter axial length (24.0 ± 1.8 mm vs 27.0 ± 3.3 mm; p < 0.001), higher prevalence (27/29 vs 12/54; p < 0.001) and longer width (213 ± 125 μm vs 96 ± 282 μm; p < 0.0001) of parapapillary alpha zone, and thicker BM in parapapillary beta zone (8.4 ± 2.7 μm vs 3.9 ± 2.0 μm; p < 0.001) and alpha zone (6.6 ± 3.9 μm vs 4.4 ± 1.5 μm; p = 0.02). Prevalence of parapapillary RPE-drusen was 27 (69%) out of 39 eyes with alpha zone. Beneath the RPE-drusen and in total alpha zone, choriocapillaris was open, while it was closed in the central part of parapapillary beta zone. BM thickness was thicker (p = 0.001) in alpha zone than beta zone, where it was thicker (p < 0.001) than in the region outside of alpha/beta zone. BM thickness outside of alpha/beta zone was not correlated with prevalence of parapapillary RPE-drusen (p = 0.47) or axial length (p = 0.31). RPE cell density was higher in alpha zone than in the region adjacent to alpha zone (22.7 ± 7.3 cells/240 μm vs 18.3 ± 4.1 cells/240 μm; p < 0.001). In the parapapillary RPE-drusen, RPE cells were connected with a PAS-positive basal membrane., Conclusions: Parapapillary RPE-drusen as fibrous pseudo-metaplasia of the RPE were associated with shorter axial length, higher prevalence and larger size of alpha zone, and thicker BM in alpha zone and beta zone. The RPE-drusen may be helpful to differentiate glaucomatous parapapillary beta zone from myopic beta zone., (© 2023 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Due to the increasing prevalence of high myopia around the world, structural and functional damages to the optic nerve in high myopia has recently attracted much attention. Evidence has shown that high myopia is related to the development of glaucomatous or glaucoma-like optic neuropathy, and that both have many common features. These similarities often pose a diagnostic challenge that will affect the future management of glaucoma suspects in high myopia. In this review, we summarize similarities and differences in optic neuropathy arising from non-pathologic high myopia and glaucoma by considering their respective structural and functional characteristics on fundus photography, optical coherence tomography scanning, and visual field tests. These features may also help to distinguish the underlying mechanisms of the optic neuropathies and to determine management strategies for patients with high myopia and glaucoma., (Copyright © 2024. Published by Elsevier Ltd.)

Aims: To investigate the association between the backward configuration of the peripapillary sclera (PPS), measured as PPS angle (PPSA), and presence and extent of parapapillary gamma zone., Methods: Out of the population-based Beijing Eye Study 2011, we randomly selected individuals free of optic nerve and retinal diseases. With Spectralis optical coherence tomography, we measured gamma zone (zone free of Bruch's membrane (BM)) and determined the PPSA, defined as the angle between the anterior scleral surface lines from both sides of the optic nerve head (ONH)., Results: The study included 678 individuals with age of 59.5±7.6 years (range: 50-90) and axial length of 23.5±1.3 mm (20.9-29.2). Gamma zone was more prevalent in eyes with larger PPSA (p=0.006) after adjustment for axial length (p<0.001) and BM opening area (p<0.001). Gamma zone width was positively associated with PPSA, axial length and BM opening area (all p<0.001) in multivariable analysis. Circular gamma zone was accompanied with larger PPSA as compared with focal gamma zone (19.9°±7.2° vs 6.3°±5.3°, p<0.001). Focal temporal gamma and focal inferior gamma had similar mean PPSA (p=0.69). However, the horizontal PPSA was significantly larger than the vertical PPSA in inferior gamma (6.9°±6.3° vs 4.7°±6.6°; p=0.005), while they were comparable in temporal gamma (6.1°±5.8° vs 6.3°±6.4°; p=0.073)., Conclusions: A more backward bowing of the PPS was linearly and spatially associated with the presence, size and extent of gamma zone. It suggested that the BM and the sclera were closely related in participating the biomechanical behaviour of the ONH., Competing Interests: Competing interests: Financial Disclosures: JBJ: European patent EP 3271392, JP 2021-119187 and US 2021 0340237 A1: Agents for use in the therapeutic or prophylactic treatment of myopia or hyperopia. Other authors: none., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Prcis: An optical coherence tomography (OCT)-based multimodal deep learning (DL) classification model, including texture information, is introduced that outperforms single-modal models and multimodal models without texture information for glaucoma diagnosis in eyes with and without high myopia., Background/aims: To evaluate the diagnostic accuracy of a multimodal DL classifier using wide OCT optic nerve head cube scans in eyes with and without axial high myopia., Materials and Methods: Three hundred seventy-one primary open angle glaucoma (POAG) eyes and 86 healthy eyes, all without axial high myopia [axial length (AL) ≤ 26 mm] and 92 POAG eyes and 44 healthy eyes, all with axial high myopia (AL > 26 mm) were included. The multimodal DL classifier combined features of 3 individual VGG-16 models: (1) texture-based en face image, (2) retinal nerve fiber layer (RNFL) thickness map image, and (3) confocal scanning laser ophthalmoscope (cSLO) image. Age, AL, and disc area adjusted area under the receiver operating curves were used to compare model accuracy., Results: Adjusted area under the receiver operating curve for the multimodal DL model was 0.91 (95% CI = 0.87, 0.95). This value was significantly higher than the values of individual models [0.83 (0.79, 0.86) for texture-based en face image; 0.84 (0.81, 0.87) for RNFL thickness map; and 0.68 (0.61, 0.74) for cSLO image; all P ≤ 0.05]. Using only highly myopic eyes, the multimodal DL model showed significantly higher diagnostic accuracy [0.89 (0.86, 0.92)] compared with texture en face image [0.83 (0.78, 0.85)], RNFL [0.85 (0.81, 0.86)] and cSLO image models [0.69 (0.63, 0.76)] (all P ≤ 0.05)., Conclusions: Combining OCT-based RNFL thickness maps with texture-based en face images showed a better ability to discriminate between healthy and POAG than thickness maps alone, particularly in high axial myopic eyes., Competing Interests: Disclosure: M.A.F.: research support: Topcon Corporation, Heidelberg Engineering. R.N.W.: consultant: AbbVie, Alcon, Allergan, Amydis, Editas, Eyenovia, Equinox, Iantrek, iStar Medical, Nicox, Santen, Topcon. Research support: Heidelberg Engineering, Carl Zeiss Meditec, Centervue, Konan Medical, Optovue, Topcon, Zilia. L.M.Z.: consultant: AbbVie and Topcon. Research Support: Carl Zeiss Meditec, Heidelberg Engineering, Optovue, Topcon Medical System Inc. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Myopic axial elongation is associated with various non-pathological changes. These include a decrease in photoreceptor cell and retinal pigment epithelium (RPE) cell density and retinal layer thickness, mainly in the retro-equatorial to equatorial regions; choroidal and scleral thinning pronounced at the posterior pole and least marked at the ora serrata; and a shift in Bruch's membrane opening (BMO) occurring in moderately myopic eyes and typically in the temporal/inferior direction. The BMO shift leads to an overhang of Bruch's membrane (BM) into the nasal intrapapillary compartment and BM absence in the temporal region (i.e., parapapillary gamma zone), optic disc ovalization due to shortening of the ophthalmoscopically visible horizontal disc diameter, fovea-optic disc distance elongation, reduction in angle kappa, and straightening/stretching of the papillomacular retinal blood vessels and retinal nerve fibers. Highly myopic eyes additionally show an enlargement of all layers of the optic nerve canal, elongation and thinning of the lamina cribrosa, peripapillary scleral flange (i.e., parapapillary delta zone) and peripapillary choroidal border tissue, and development of circular parapapillary beta, gamma, and delta zone. Pathological features of high myopia include development of macular linear RPE defects (lacquer cracks), which widen to round RPE defects (patchy atrophies) with central BM defects, macular neovascularization, myopic macular retinoschisis, and glaucomatous/glaucoma-like and non-glaucomatous optic neuropathy. BM thickness is unrelated to axial length. Including the change in eye shape from a sphere in emmetropia to a prolate (rotational) ellipsoid in myopia, the features may be explained by a primary BM enlargement in the retro-equatorial/equatorial region leading to axial elongation., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: To describe the optic nerve head (ONH) abnormalities in nonpathologic highly myopic eyes based on swept-source optical coherence tomography (OCT) and the relationship with visual field (VF)., Design: Secondary analysis from a longitudinal cohort study., Methods: Highly myopic patients without myopic maculopathy of category 2 or higher were enrolled. All participants underwent a swept-source OCT examination focused on ONH. We differentiated between 3 major types (optic disc morphologic abnormality, papillary/peripapillary tissue defect, and papillary/peripapillary schisis) and 12 subtypes of ONH abnormalities. The prevalence and characteristics of ONH abnormalities and the relationship with VF were analyzed., Results: A total of 857 participants (1389 eyes) were included. Among the 1389 eyes, 91.86%, 68.61%, and 34.92% of them had at least 1, 2, or 3 ONH abnormalities, respectively, which corresponded to 29.55%, 31.79%, and 35.67% of VF defects, respectively. Among the 12 subtypes of the 3 major types, peripapillary hyperreflective ovoid mass-like structure, visible retrobulbar subarachnoid space, and prelaminar schisis were the most common, respectively. Perimetric defects corresponding to OCT abnormalities were more commonly found in eyes with peripapillary retinal detachment, peripapillary retinoschisis, and peripapillary hyperreflective ovoid mass-like structure. Glaucoma-like VF defects were more common in eyes with deep optic cups (28.17%) and with optic disc pit/pit-like change (18.92%)., Conclusions: We observed and clarified the ONH structural abnormalities in eyes with nonpathologic high myopia. These descriptions may be helpful to differentiate changes in pathologic high myopia or glaucoma., (Copyright © 2023 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

Purpose: To search for histologic differences in the beta zone between myopic eyes versus eyes with secondary angle-closure glaucoma., Methods: The histomorphometric study consisted of human eyes enucleated due to uveal melanomas or secondary angle-closure glaucoma., Results: The study included 100 eyes (age: 62.1 ± 15.1 years; axial length: 25.6 ± 3.1 mm; range: 20.0-35.0 mm). In non-highly myopic glaucomatous eyes compared with non-highly myopic nonglaucomatous eyes, the parapapillary alpha zone was longer (223 ± 168 µm vs. 125 ± 128 µm; P = 0.03), beta zone prevalence (15/20 vs. 6/41; P < 0.001) and length (277 ± 245 µm vs. 44 ± 150 µm; P = 0.001) were higher, and RPE cell density in the alpha zone and alpha zone border was lower (all P < 0.05). In highly myopic nonglaucomatous eyes compared with non-highly myopic glaucomatous eyes, parapapillary RPE drusen prevalence (2/19 vs. 10/10; P = 0.01) and alpha zone prevalence (2/19 vs. 16/20; P < 0.001) and length (23 ± 68 µm vs. 223 ± 168 µm; P < 0.001) were lower. In non-highly myopic glaucomatous eyes, Bruch's membrane (BM) thickness decreased (P < 0.001) from the beta zone (6.0 ± 3.1 µm) to the alpha zone (5.1 ± 4.3 µm) and peripheral to it (3.0 ± 0.9 µm). In highly myopic nonglaucomatous eyes, BM thickness did not differ (P > 0.10) between all three regions. In the total study population, RPE cell density in the alpha zone (24.5 ± 9.3 cells/240 µm) was higher than at the alpha zone border (19.2 ± 4.8 cells/240 µm; P < 0.001) or peripheral to it (19.0 ± 3.6 cells/240 µm; P < 0.001)., Conclusions: The glaucomatous beta zone in eyes with chronic angle-closure glaucoma (with the alpha zone, parapapillary RPE drusen, thickened BM, and higher RPE cell count in the adjacent alpha zone) differs histologically from the myopic beta zone (characterized by the absence of the alpha zone and parapapillary RPE drusen, unremarkable BM thickness, and unremarkable parapapillary RPE). The differences suggest different etiologies of the glaucomatous versus myopic beta zone.

Purpose: To describe nonpathological myopia-related characteristics of the human eye., Methods: Based on histomorphometric and clinical studies, qualitative and quantitative findings associated with myopic axial elongation are presented., Results: In axial myopia, the eye changes from a spherical shape to a prolate ellipsoid, photoreceptor, and retinal pigment epithelium cell density and total retinal thickness decrease, most marked in the retroequatorial region, followed by the equator. The choroid and sclera are thin, most markedly at the posterior pole and least markedly at the ora serrata. The sclera undergoes alterations in fibroblast activity, changes in extracellular matrix content, and remodeling. Bruch's membrane (BM) thickness is unrelated to axial length, although the BM volume increases. In moderate myopia, the BM opening shifts, usually toward the fovea, leading to the BM overhanging into the nasal intrapapillary compartment. Subsequently, the BM is absent in the temporal region (such as parapapillary gamma zone), the optic disc takes on a vertically oval shape, the fovea-optic disc distance elongates without macular BM elongation, the angle kappa reduces, and the papillomacular retinal vessels and nerve fibers straighten and stretch. In high myopia, the BM opening and the optic disc enlarge, the lamina cribrosa, the peripapillary scleral flange (such as parapapillary delta zone) and the peripapillary choroidal border tissue lengthen and thin, and a circular gamma and delta zone develop., Conclusions: A thorough characterization of ocular changes in nonpathological myopia are of importance to better understand the mechanisms of myopic axial elongation, pathological structural changes, and psychophysical sequelae of myopia on visual function.

The study aims to assess the thickness of the retinal outer nuclear layer (ONL), ellipsoid zone (EZ) and photoreceptor outer segment (POS) band in various macular regions and its associations with axial length and other parameters. Participants of the Beijing Eye Study 2011 underwent a series of examinations including spectral-domain optical coherence tomography of the macula. The current study included 2213 participants without retinal or optic nerve diseases (age: 61.7 ± 8.4 years; range 50-93 years); axial length: 23.15 ± 0.95 mm; range 18.96-29.15 mm). The ONL (fovea: 98.9 ± 8.8 µm), EZ (fovea: 24.1 ± 0.5 µm) and POS band (fovea: 24.3 ± 3.5 µm) were the thickest (P < 0.001) in the fovea (defined as the thinnest central point), followed by the temporal inner, nasal inner, inferior inner, superior inner, inferior outer, temporal outer, nasal outer, and superior outer region. In multivariable analysis, a thicker retinal ONL was associated (correlation coefficient r: 0.40) with shorter axial length (beta: - 0.14; P < 0.001) and shorter disc-fovea distance (beta: - 0.10; P = 0.001), after adjusting for younger age (beta: - 0.26; P < 0.001), male sex (beta: 0.24; P < 0.001), lower serum cholesterol concentration (beta: - 0.05; P = 0.04), and thicker subfoveal choroidal thickness (beta: 0.08; P < 0.001). The POS thickness increased with shorter axial length (beta: - 0.06; P < 0.001) and shorter optic disc-fovea distance (beta: - 0.05; P = 0.03), after adjusting for younger age (beta: - 0.34; P < 0.001), male sex (beta: 0.15; P < 0.001), and thicker subfoveal choroidal thickness (beta: 0.24; P < 0.001). As a conclusion, the photoreceptor ONL, EZ and POS band vary in thickness between different macular regions and differ in their correlations with axial length, disc-fovea distance, age, sex, and subfoveal choroidal thickness. The ONL thickness decrease with longer axial length and longer disc-fovea distance may point to an axial elongation-associated retinal stretching in the macula., (© 2023. The Author(s).)

Purpose: To assess prevalence and associated factors of parapapillary gamma zone enlargement (GZE)., Methods: Using fundus photographs and optical coherence tomographic images of participants of the population-based Beijing Eye Study, we examined gamma zone changes in a 10-year follow-up., Results: The study included 89 highly myopic eyes (61 participants; age: 65.0 ± 9.8 years) and 86 randomly selected non-highly myopic eyes. GZE prevalence was significantly higher in highly myopic eyes than non-highly myopic eyes (75/89; 84%; 95% CI: 77, 92 versus 18/86; 21%; 95% CI:12, 30; p < 0.001). None of the eyes showed a reduction in gamma zone size. Higher prevalence of segmental GZE without enlargement of Bruch's membrane opening (BMO) (mean: 26/175; 14.9%; 95% CI: 9.5, 20.2) was associated with optic disc size reduction (OR: 43.3; 95% CI: 10.9, 172; p < 0.001), disc-fovea distance elongation (OR: 15.4; 95% CI: 3.12, 76.4; p = 0.001) and lower prevalence of high axial myopia (OR: 0.08; 95% CI: 0.01, 0.44; p = 0.001). Higher prevalence of circular GZE (mean: 38/175; 21.7%; 95% CI: 16, 28) was correlated with optic disc enlargement (OR: 4.30; 95% CI: 1.58, 11.7; p = 0.004), and higher prevalence of myopic maculopathy progression (OR: 4.04; 95% CI: 1.60, 10.2; p = 0.003), or alternatively, higher prevalence of high myopia (OR: 4.44; 95% CI: 1.76, 11.2; p = 0.002). Circular GZE or BMO enlargement was associated with lower prevalence of macular BM defect enlargement (p = 0.035). GZE occurred perpendicular to the orientation of myopic lacquer cracks in 12 out of 17 (71%; 95% CI: 46, 95) eyes with lacquer cracks. Segmental GZE occurred in 49 (89%) out of 55 eyes in the same direction as shortening of the disc diameter developed., Conclusions: The observations support the possibility of a posterior myopic axial elongation-associated BMO shift, leading to a segmental GZE in non-highly myopic eyes, followed by a circular GZE in highly myopic eyes. Large gamma zone might be protective against macular Bruch's membrane defects., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background: To assess prevalence and associated factors of changes in the ophthalmoscopic optic disc size and shape., Methods: The case-control study included all highly myopic eyes (myopic refractive error ≤-6.0 diopters) and a randomly selected group of non-highly myopic eyes, examined in the population-based Beijing Eye Study 2001 and 2011., Results: The study included 89 highly myopic eyes (age:65.0±9.8 years) and 86 non-highly myopic eyes. Reduction in ophthalmoscopic disc size (prevalence, high myopia: 30 (33.7%) eyes; non-high myopia: 7 (8.1%) eyes) was associated with non-circular gamma zone enlargement (OR: 19.4; 95% CI: 6.7 to 56.6; p<0.001) and disc-fovea line elongation (OR: 2.80;95% CI: 1.12 to 6.98; p=0.03). Disc size reduction was correlated with a disc diameter shortening in direction of the widest gamma zone enlargement (correlation coefficient r=34; p=0.01). The perpendicular disc diameter remained mostly unchanged, resulting in an ovalisation of the ophthalmoscopic disc shape. Enlargement of the ophthalmoscopic disc size (prevalence, high myopia: 22 (24.7%) eyes; non-high myopia: 4 (4.7%) eyes) was associated with circular gamma zone enlargement (4.99; 95% CI: 1.95 to 12.8; p=0.001) and high myopia (OR: 4.29; 95% CI: 1.34 to 13.8; p=0.01)., Conclusions: Myopic axial elongation may lead first to a Bruch's membrane (BM) opening (BMO) shift into the foveal direction leading to BM overhanging into the nasal intrapapillary compartment, development and enlargement of gamma zone at the temporal disc side, reduction in the ophthalmoscopically visible disc area and ovalisation of the ophthalmoscopic disc shape. In a second step, an axial elongation-associated BMO enlargement may lead to a circular gamma zone increase and, due to the retraction of BM at the nasal disc border, to an enlargement of the ophthalmoscopically visible optic disc., Competing Interests: Competing interests: JBJ and RAJ: European patent application 16 720 043.5 and US patent application US 2019 0085065 A1: Agents for use in the therapeutic or prophylactic treatment of myopia or hyperopia). JBJ: Advisory Board Novartis; Patent holder with Biocompatibles UK. (Farnham, Surrey, UK) (Title: Treatment of eye diseases using encapsulated cells encoding and secreting neuroprotective factor and/or anti-angiogenic factor; Patent number: 20120263794), Patent application: Agents for the use in the therapeutic or prophylactic treatment of retinal pigment epithelium-associated diseases., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The purpose of the study was to examine peculiarities of the inner limiting membrane (ILM) in axially elongated eyes. The histomorphometric study included human globes enucleated due to reasons such as painful secondary angle-closure glaucoma or malignant uveal melanomas. Using light microscopy, we searched for regions with ILM-specific features in association with a marked axial elongation. Out of 279 eyes (279 patients) (mean age: 61.8 ± 13.9 years; axial length: 25.5 ± 3.1 mm (range: 20.0-37.0 mm)), two eyes (axial length: 30 mm and 34 mm, respectively) showed one region and two regions, respectively, characterized by ILM presence and absence of all other retinal layers, retinal pigment epithelium, Bruch´s membrane (BM) and choroid. The length of these regions, called ILM-bridges, was 1.06 mm, 0.73 mm, and 0.62 mm, respectively. All ILM-bridges were spatially associated with a larger, underlying BM defect and with localized scleral thinning without a staphylomatous scleral configuration. The distance between the ILM-bridges and the optic disc ranged between 1.92 mm and 4.21 mm. In univariable analysis, ILM-bridge number increased with longer axial length (beta: 0.19; P = 0.002) and higher BM defect prevalence (beta: 0.21; P = 0.001), while in multivariable analysis, the ILM-bridges number remained to be significantly correlated only with a higher prevalence of BM defect (beta: 0.15; P = 0.048). ILM-bridges occur in eyes with pathologic myopia in spatial association with underlying, larger BM defects. They may be due to an axial elongation-associated local stretching and rupture of all other retinal layers, caused by the BM defect-related enlargement of the retinal undersurface. Future studies may explore whether these histologic observations support the notion of the ILM having a relatively high biomechanical strength against myopic stretching-associated forces., (© 2022. The Author(s).)

Aims: To investigate the distribution and associations of the circumpapillary retinal nerve fibre layer thickness (RNFLT) profile, characterised as peak height and peak position, in healthy eyes., Methods: 667 healthy participants (294 male) were randomly selected from the Beijing Eye Study 2011. RNFLT was measured at 768 points at 3.4 mm circumpapillary position using spectral-domain optical coherence tomography (OCT). The location and height of the superior temporally peak (Peak ST ), superior nasal peak (Peak SN ) and inferior temporal peak (Peak IT ) were assessed., Results: The RNFLT was thickest at Peak IT (194±25 µm; location: 288±12°), followed by Peak ST (182±25 µm; 73±10°) and Peak SN (125±23 µm; 135°±13°). In multivariable analysis, peak RNFLT decreased with longer axial length (p<0.001; correlation coefficient beta: -0.18 to -0.15; all peaks), older age (all p<0.01, beta: -0.10; Peak ST and Peak IT ), female gender (p=0.026, beta: -0.09; Peak ST ), and larger parapapillary gamma zone and beta zone width (p≤0.004, beta: -0.16 to-0.11; Peak SN ). The temporal peaks were located more closely to the horizontal line in women (p≤0.020, beta: 0.09-0.11) and with longer axial length (p<0.001, beta: 0.27-0.31), while they were located more inferiorly in eyes with larger Bruch's membrane openings (BMOs) (p≤0.01, beta:0.10~0.11)., Conclusions: Peak RNFLT decreased by 0.34 µm for each increase of year in age (Peak ST and Peak IT ), by 3.2-3.5 µm for each 1 mm increase in axial length (all three peaks), and was 4.5 µm thinner in women than in men. The position of temporal peaks depended on gender, axial length and BMO diameter. These associations should be taken into count in OCT-based RNFLT assessment for disease finding, especially in glaucoma evaluation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To examine the elongation of the retina and ciliary body in relation to myopic axial elongation., Methods: Using light microscopy, we histomorphometrically measured in enucleated human globes the length of the retina from the ora serrata to the optic disc borders. The total retinal length was the mean of the retinal length measurements obtained on both sides of the optic disc. We additionally determined the length of the ciliary body between the ora serrata and the scleral spur., Results: The study included 174 eyes (mean age, 61.7 ± 14.8 years; range, 24-89 years) with a mean sagittal eye diameter of 25.9 ± 3.2 mm (range, 21.0-37.0 mm). Retinal length (beta, 0.81; nonstandardized regression coefficient B, 0.73; 95% confidence interval (CI), 0.65-0.81; P < 0.001) and ciliary body length elongated (beta, 0.49; nonstandardized regression coefficient B, 0.16; 95% CI, 0.12-0.20; P < 0.001) with a longer sagittal eye diameter. Retinal length and ciliary body length were associated with each other (beta, 0.34; nonstandardized regression coefficient B, 0.12; 95% CI, 0.07-0.17)., Conclusions: The retina elongates by 0.73 mm (95% CI, 0.65-0.81) and the ciliary body by 0.16 mm (95% CI, 0.12-0.20) for each millimeter of axial elongation. With the inner limiting membrane and retinal nerve fibers forming the only structures connecting the deeper retinal layers with the optic disc, retinal elongation may be associated with a stretching of the retinal nerve fibers, potentially leading to optic nerve damage in highly myopic eyes, and with an increased strain within the inner limiting membrane, potentially leading to an intraretinal elevation at the posterior pole with the sequel of a myopic maculoschisis.

Purpose: Previous studies have shown that the retinal nerve fibre layer (RNFL) thickness as surrogate of the optic nerve decreases with longer axial length. We explored which explanatory parameters might explain that association., Methods: Participants of the population-based Beijing Eye Study 2011 without any retinal or optic nerve disease were selected based on a refractive error-based stratified randomization., Results: The study included of 632 participants (age: 59.1 ± 7.3 years; axial length: 23.5 ± 1.2 mm; range: 20.88-28.68 mm). Thicker RNFL (mean: 101.0 ± 10.0 μm) was associated (multivariable analysis) with smaller parapapillary gamma zone (defined as Bruch's membrane-free parapapillary region) (standardized regression coefficient beta: -0.13; non-stadardized regression coefficient B: -0.008; 95% confidence interval (CI): -0.014, -0.003; p = 0.005) and shorter disc-fovea distance (beta: -0.15; B: -3.91; 95% CI: -6.60; -1.22; p = 0.004), after adjusting for age (beta: -0.22; B: -030; 95% CI: -0.41, -0.19; p < 0.001), gender (beta: 0.12; B: 2.37; 95% CI 0.77, 3.97; p = 0.004) and larger optic disc area (beta: 0.12; B: 0.12; 95% CI: 2.14; 95% CI: 0.54, 3.73; p = 0.009). RNFL thickness decreased by 8 μm (95% CI: 3, 14) for each mm increase in gamma zone width, and by 3.91 μm (95% CI: 1.22, 6.60) for each mm elongation of the disc-fovea distance. If disc-fovea distance and gamma zone width were replaced by axial length, the latter was correlated with RNFL thickness (beta: -0.37; B: -3.12; 95% CI: -3.88, -2.35; p < 0.001). Longer disc-fovea distance was directly associated with larger gamma zone (beta: 0.50; B: p < 0.001)., Conclusions: The RNFL thickness decrease with longer axial length is associated with a longer optic disc-fovea distance and larger parapapillary gamma zone. Longer disc-fovea distance and larger gamma zone lead to an elongation and stretching of the retinal nerve fibres, potentially causing a thinning or loss of the nerve fibres. It may explain the occurrence of visual field defects in some non-glaucomatous highly myopic eyes without macular correlates of the perimetric defects., (© 2022 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To develop a classification system of visual field (VF) abnormalities in highly myopic eyes with and without glaucoma., Design: Secondary analysis of VF data from a longitudinal cohort study., Participants: One thousand eight hundred ninety-three VF tests from 1302 eyes (825 individuals)., Methods: All participants underwent VF testing (Humphrey 24-2 Swedish interactive threshold algorithm standard program; Carl Zeiss Meditec) and detailed ophthalmic examination. A comprehensive set of VF defect patterns was defined via observation of the 1893 VF reports, literature review, and consensus meetings. The classification system comprised 4 major types of VF patterns, including normal type, glaucoma-like defects (paracentral defect, nasal step, partial arcuate defect, arcuate defect), high myopia-related defects (enlarged blind spot, vertical step, partial peripheral rim, nonspecific defect), and combined defects (nasal step with enlarged blind spot). A subset (n = 1000) of the VFs was used to evaluate the interobserver and intraobserver agreement and weighted κ values of the classification system by 2 trained readers. The prevalence of various VF patterns and their associated factors were determined., Main Outcome Measures: The classification of VF in highly myopic eyes and its associated risk factors., Results: We found that normal type, glaucoma-like defects, high myopia-related defects, and combined defects accounted for 74.1%, 10.8%, 15.0%, and 0.1% of all unique VF tests, respectively. The interobserver and intraobserver agreements were > 89%, and the corresponding κ values were 0.86 or more between readers. Both glaucoma-like and high myopia-related VF defects were associated with older age (odds ratios [ORs], 1.07 [95% confidence interval (CI), 1.04-1.10; P < 0.001] and 1.06 [95% CI, 1.04-1.10; P < 0.001]) and longer axial length (ORs, 1.65 [95% CI, 1.32-2.07; P < 0.001] and 1.37 [95% CI, 1.11-1.68; P = 0.003]). Longer axial length showed a stronger effect on the prevalence of glaucoma-like VF defects than on the prevalence of high myopia-related VF defects (P = 0.036)., Conclusions: We propose a new and reproducible classification system of VF abnormalities for nonpathologic high myopia. Applying a comprehensive classification system will facilitate communication and comparison of findings among studies., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Myopic axial elongation may be due to an equatorial enlargement of Bruch's membrane (BM), leading to a prolate eye shape and increasing strain with BM and the retinal pigment epithelium (RPE) layer at the posterior pole. The increased BM strain may cause an enlargement of Bruch's membrane opening (BMO) of the optic nerve head, with the subsequent development and enlargement of parapapillary gamma zone as BM-free parapapillary zone. The increased strain within BM and RPE may also cause lacquer cracks (LCs) as linear breaks in the RPE and / or BM. Studies suggested that a more marked gamma zone enlargement is associated with lower prevalence of LCs or macular BM defects. Here report on the disappearance of a LC during a 10-year follow-up of a highly myopic eye, concurrent with a marked increase in gamma zone., Case Presentation: A 56-year-old woman showed in her right eye (axial length measured 30.69 mm) a LC, vertically oval optic disc, and parapapillary gamma zone in 2001. When re-examined in 2006, gamma zone had enlarged, while the LC was no longer detectable. In 2011, the LC was not visible neither upon ophthalmoscopy and or upon optical coherence tomography (OCT), while gamma zone had further enlarged. The gamma zone enlargement occurred in a direction perpendicular to the direction of the former LC., Conclusions: The observation suggest that a LC can decrease in width, in temporal association with an enlargement of gamma zone. It fits with the notion that an enlargement of the BMO (i.e., enlarging gamma zone) may lead to a relaxation of the BM strain and subsequently to a decrease in the width of the LC., (© 2021. The Author(s).)

Purpose: To assess the prevalence of myelinated retinal nerve fibers (MRNFs), the rate of their change in a 10-year follow-up, and associations with ocular and systematic parameters in a population-based cohort., Design: Longitudinal population-based cohort study., Methods: The Beijing Eye study including 4,439 participants aged 40+ years in 2001 and was repeated in 2011, with 2,695 individuals (66.4% of the surviving) being re-examined in 2011. All participants underwent detailed physical and ocular examinations. MRNFs were diagnosed on fundus photographs and their change was assessed using a flicker method of fundus photographs., Results: Out of 35 eyes (29 participants) with detected MRNFs at baseline (mean prevalence: 0.4% ± 0.26% per eye or 0.7% ± 0.41% per individual), 23 eyes from 20 individuals (17 [85%] participants with unilateral MRNFs) were re-examined in 2011. MRNF enlargement was detected in all 19 eyes (100%) with clear fundus photographs. The mean MRNF area increased from 4,233 ± 3,670 µm 2 (range: 178-11,643 µm 2 ) at baseline to 5,243 ± 4,092 µm 2 (range: 196-13,297 µm 2 ) at follow-up (P < .001), by 1,010 ± 1,026 µm 2 (18-3,967 µm 2 ) or by 47% ± 74% (9%-315%). A larger MRNF increase was associated with an MRNF location distant from the optic disc as compared to a juxtapapillary location (P = .001, standardized regression coefficient beta: -0.53), smaller MRNF area at baseline (P = .006, beta: -0.34), and higher serum concentration of low-density lipoproteins (LDL) (P < .001, beta: 0.57)., Conclusions: MRNFs (mean prevalence per eye: 0.4%) showed, in association with higher LDL serum concentration and peripheral located MRNF, an enlargement during a 10-year follow-up, while in the same period no new MRNFs were detected in the total study cohort., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to investigate the optic disc morphology in primary angle-closure glaucoma (PACG) versus primary open-angle glaucoma (POAG) in South Indians., Methods: A total of 60 patients (60 eyes) with PACG and 52 patients (52 eyes) with POAG were included in a cross-sectional observational study. The glaucoma diagnosis was based on a glaucomatous appearance of the optic disc correlating with visual field defects. The glaucoma was graded as early, moderate, or severe, depending upon perimetric loss. All patients underwent an ophthalmic evaluation, including visual field examination and planimetric analysis of 30° stereoscopic color optic disc photographs., Results: The POAG and PACG groups did not differ significantly in a disc or rim area, rim width, and frequencies of disc hemorrhages or rim notches. However, early POAG group (n = 15) had a significantly deeper cup depth (P = 0.01), larger beta zone (P = 0.01), and a higher frequency of localized retinal nerve fiber layer (RNFL) defects (P = 0.02) than early PACG (n = 20)., Conclusion: In the early stage of the disease, POAG compared to PACG may be characterized by deeper disc cupping, a larger beta zone of peripapillary atrophy, and a higher frequency of localized RNFL defects. Such differences in early glaucoma may suggest differences in pathophysiology in POAG and PACG., Competing Interests: None

The optic nerve head can morphologically be differentiated into the optic disc with the lamina cribrosa as its basis, and the parapapillary region with zones alpha (irregular pigmentation due to irregularities of the retinal pigment epithelium (RPE) and peripheral location), beta zone (complete RPE loss while Bruch's membrane (BM) is present), gamma zone (absence of BM), and delta zone (elongated and thinned peripapillary scleral flange) within gamma zone and located at the peripapillary ring. Alpha zone is present in almost all eyes. Beta zone is associated with glaucoma and may develop due to a IOP rise-dependent parapapillary up-piling of RPE. Gamma zone may develop due to a shift of the non-enlarged BM opening (BMO) in moderate myopia, while in highly myopic eyes, the BMO enlarges and a circular gamma zone and delta zone develop. The ophthalmoscopic shape and size of the optic disc is markedly influenced by a myopic shift of BMO, usually into the temporal direction, leading to a BM overhanging into the intrapapillary compartment at the nasal disc border, a secondary lack of BM in the temporal parapapillary region (leading to gamma zone in non-highly myopic eyes), and an ocular optic nerve canal running obliquely from centrally posteriorly to nasally anteriorly. In highly myopic eyes (cut-off for high myopia at approximately -8 diopters or an axial length of 26.5 mm), the optic disc area enlarges, the lamina cribrosa thus enlarges in area and decreases in thickness, and the BMO increases, leading to a circular gamma zone and delta zone in highly myopic eyes., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This study characterizes differences in glaucomatous eyes with and without high axial myopia using custom automated analysis of OCT images. 452 eyes of 277 glaucoma patients were stratified into non (n = 145 eyes), mild (n = 214 eyes), and high axial myopia (axial length (AL) > 26 mm, n = 93 eyes). Optic disc ovality index, tilt and rotation angle of Bruch´s membrane opening (BMO) and peripapillary choroidal thickness (PCT) were calculated using automated and deep learning strategies. High myopic optic discs were more oval and had larger BMO tilt than mild and non-myopic discs (both p < 0.001). Mean PCT was thinnest in high myopic eyes followed by mild and non-myopic eyes (p < 0.001). BMO rotation angle, global retinal nerve fiber layer (RNFL) thickness and BMO-minimum rim width (MRW) were similar among groups. Temporal RNFL was thicker and supranasal BMO-MRW was thinner in high myopic eyes. BMO tilt and PCT showed moderate and temporal RNFL and nasal BMO-MRW showed weak but significant associations with AL in multivariable analyses (all p < 0.05). Large BMO tilt angle and thin PCT are characteristics of highly myopic discs and were not associated with severity of glaucoma. Caution should be exercised when using sectoral BMO-MRW and RNFL thickness for glaucoma management decisions in myopic eyes.

Purpose: To assess the spatial relationship between the locations of the parapapillary gamma zone and the fovea., Methods: In a non-glaucomatous subgroup of the population-based Beijing Eye Study population, we measured the mean angle between the optic disc-fovea line and the horizontal (disc-fovea angle), the vertical distance of the fovea from the horizontal through the optic disc center (fovea vertical distance), and the location and width of the widest part of parapapillary gamma zone., Results: The study included 203 individuals (203 eyes; mean axial length, 24.4 ± 1.5 mm; range, 22.03-28.87 mm). The widest gamma zone part was located most often temporal horizontally (51.7%), then inferiorly (43.8%), superiorly (2.5%), and nasally (2.0%). The disc-fovea angle (mean, 7.50° ± 4.00°; range, -6.30° to -23.25°) was significantly higher (P = 0.003; i.e., fovea located more inferiorly) in eyes with the widest gamma zone inferiorly (8.46° ± 4.37°) than in eyes with the widest gamma zone temporally (6.71° ± 3.46°) and in eyes with the widest gamma zone temporally, superiorly, or nasally combined (6.75° ± 3.53°; P = 0.003). The fovea vertical distance (mean, 0.65 ± 0.33 mm; range, -0.20 to 1.67 mm) was longer (P = 0.001; i.e., fovea located more inferiorly) in eyes with the widest gamma zone inferiorly (0.73 ± 0.33 mm) than in eyes with the widest gamma zone temporally (0.58 ± 0.30 mm) and in eyes with a temporal, superior, or nasal gamma zone combined (0.58 ± 0.31 mm; P = 0.001). The fovea vertical distance increased (multivariate analysis) with the widest gamma zone location inferiorly (β = 0.25; P = 0.001) and wider width of the gamma zone (β = 0.19; P = 0.01)., Conclusions: An inferior fovea location is associated with a wider inferior gamma zone and vice versa, supporting the notion of an inferior shifting of Bruch's membrane as the cause for an inferior gamma zone.

Purpose: To assess changes in the position of lamina cribrosa pores (LCPs) induced by acute intraocular pressure (IOP) elevation., Methods: A prospective observational study. Acute angle-closure suspects who underwent the 2-hour dark room prone provocative test (DRPPT) were included. At baseline and within 5 min after the DRPPT end, tonometry, fundus photography and optical coherence tomography were performed. Optic disc photos taken before and after the DRPPT were aligned and moving distance of each visible LCP was measured (LCPMD)., Results: 38 eyes from 27 participants (age: 52.5±10.8 years) were included. The IOP rose from 16.7±3.2 mm Hg at baseline to 23.9±4.3 mm Hg at the DRPPT end. The mean lateral LCPMD was 28.1±14.6 µm (range: 5.0-77.2 µm), which increased with higher IOP rise (p=0.01) and deeper optic cup (p=0.02) in multivariate analysis. The intralamina range and SD of the LCPMD increased with younger age (p=0.01 and p=0.02, respectively) and with wider optic cup (p=0.01 and p=0.02, respectively). The LCP movements were headed to the superior direction in 12 (33%) eyes, inferior direction in 10 (28%) eyes, temporal direction in 9 (25%) eyes, and nasal direction in 5 (14%) eyes., Conclusions: IOP rise is associated with LCP movements in the frontal plane, which are more pronounced with higher IOP rise and deeper optic cup. The intralamina variability in the IOP rise-associated LCPMD increased with younger age and wider optic cup. IOP variation-associated lateral LCP movements may be of interest to elucidate glaucomatous optic nerve damage., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To study the effect of changing heart rate on the ocular pulse and the dynamic biomechanical behavior of the optic nerve head (ONH) using a comprehensive mathematical model., Methods: In a finite element model of a healthy eye, a biphasic choroid consisted of a solid phase with connective tissues and a fluid phase with blood, and the lamina cribrosa (LC) was viscoelastic as characterized by a stress-relaxation test. We applied arterial pressures at 18 ocular entry sites (posterior ciliary arteries), and venous pressures at four exit sites (vortex veins). In the model, the heart rate was varied from 60 to 120 bpm (increment: 20 bpm). We assessed the ocular pulse amplitude (OPA), pulse volume, ONH deformations, and the dynamic modulus of the LC at different heart rates., Results: With an increasing heart rate, the OPA decreased by 0.04 mm Hg for every 10 bpm increase in heart rate. The ocular pulse volume decreased linearly by 0.13 µL for every 10 bpm increase in heart rate. The storage modulus and the loss modulus of the LC increased by 0.014 and 0.04 MPa, respectively, for every 10 bpm increase in heart rate., Conclusions: In our model, the OPA, pulse volume, and ONH deformations decreased with an increasing heart rate, whereas the LC became stiffer. The effects of blood pressure/heart rate changes on ONH stiffening may be of interest for glaucoma pathology.

Beyond a cut-off value of approximately 26.5mm, the prevalence of glaucomatous or glaucoma-like optic neuropathy (GON) increases with longer axial length. In a hospital-based study, the prevalence of GON was 42% in eyes with an axial length of ≥30mm. Myopia-associated histological changes potentially associated with the increased GON prevalence are an elongation and thinning of the lamina cribrosa and peripapillary scleral flange. Correspondingly, clinical parameters associated with an increased GON prevalence were an enlargement of the optic disc and parapapillary delta zone. In addition to GON, a non-glaucomatous optic nerve damage can occur in highly myopic eyes, potentially due to a parapapillary gamma zone-associated lengthening of the retinal nerve fibers in the papillo-macular bundle. Clinically, GON and non-glaucomatous optic neuropathy should be ruled out in any highly myopic eye, in particular in those with a large optic disc, gamma zone and delta zone., (© 2020 Elsevier B.V. All rights reserved.)

The process of emmetropization is the adjustment of the length of the optical axis to the given optical properties of the cornea and lens after the end of the second year of life. Up to the end of the second year of life, the eye grows spherically. Axial elongation in the process of emmetropization after the second year of life is associated with a thinning of the retina and a reduced density of retinal pigment epithelium (RPE) cells in the equatorial and retroequatorial region, and a thinning of the choroid and sclera, starting at the equator and being most marked at the posterior pole. In contrast, retinal thickness and RPE density in the macular region and thickness of Bruch membrane (BM) in any region are independent of axial length. It led to the hypothesis that axial elongation occurs by the production of additional BM in the equatorial and retroequatorial region leading to a decreased RPE density and retinal thinning in that region and a more tube-like than spherical enlargement of the globe, without compromise in the density of the macular RPE cells and in macular retinal thickness. The increased disc-fovea distance in axially myopic eyes is caused by the development and enlargement of parapapillary, BM-free, gamma zone, whereas the length of macular BM, and indirectly macular RPE cell density, and macular retinal thickness, remain constant.

Background: Horizontal eye movements have been proposed to induce biomechanical stress and strain on optic nerve head. Since strabismus may lead to sustained adduction or abduction, we investigate the effects of long lasting unilateral horizontal strabismus on the morphology of optic disc., Methods: The observational cross-sectional study included patients with unilateral constant horizontal strabismus lasting for more than two years. The patients underwent an ophthalmological examination including refraction and morphometry of the optic nerve head. A prism cover test using right angle glass prism was performed to measure the magnitude of the ocular deviation., Results: The study included 70 patients with a unilateral constant strabismus (35 esotropic patients, 35 exotropic patients) with a mean age of 26 ± 19 years, mean refractive error of - 0.72 ± 3.3 diopters, mean axial length of 23.8 ± 1.7 mm, and a mean angle of deviation of 87 ± 36 prism diopters (Chinese right-angle glass method) in the esotropic group and - 97 ± 29 prism diopters in the exotropic group. In the whole study population and taken separately in the esotropic group and exotropic group, the disc ovality index (defined as ratio of minimal-to-maximal optic disc diameter) did not differ significantly between the deviating eyes and the contralateral fixating eyes (all P > 0.05). As a corollary, the disc ovality index and the prevalence of parapapillary beta/gamma zone did not differ significantly between the esotropic group and the exotropic group (all P > 0.05)., Conclusions: Optic disc ovality did not differ markedly among long-lasting esotropic eyes, exotropic eyes, and non-strabismic eyes. It suggests that optic disc shape may not be markedly influenced in non-highly myopic eyes by a potential backward pull of the optic nerve on the optic disc structures in adduction or abduction.

Purpose: To assess axial elongation-associated characteristics in Bruch's membrane opening (BMO) as the inner optic nerve head lamella., Methods: Participants of the population-based Beijing Eye Study without glaucoma underwent optical coherence tomography for measurement of the BMO size and shape., Results: The study included 365 individuals (mean age, 61.0 ± 8.7 years; range, 50-88 years; axial length, 24.45 ± 1.99 mm; range, 21.32-30.88 mm). Larger horizontal (mean:1.62 ± 0.28 mm) and vertical (mean: 1.74 ± 0.27 mm) BMO diameters were linearly associated with longer axial length beyond an axial length of 26.0 mm (horizontal diameter: P < 0.001; standardized regression coefficient β: 0.66; nonstandardized regression coefficient B: 0.22; 95% confidence interval (CI): 0.16, 0.27; vertical diameter: P < 0.001; β: 40; B: 0.12; 95% CI: 0.06, 0.18). In multivariable analysis, wider largest gamma zone was associated with larger intrapapillary Bruch's membrane (BM) overhanging on the side opposite to the largest gamma zone (P = 0.006; β: 0.14; B: 0.35; 95% CI: 0.10, 0.60) and with longer horizontal BMO diameter (P < 0.001; β: 0.46; B: 0.59; 95% CI: 0.46, 0.73). The widest BM overhanging location (superior to nasal) was inversely correlated with the widest gamma zone location (inferior to temporal). Within the axial length group of ≥28.0 mm, eyes with macular BM defects had a less markedly increased BMO than those without macular BM defects (2.27 ± 0.18 vs. 2.71 ± 0.41 mm; P = 0.019). The difference between horizontal BMO diameter minus horizontal gamma zone width decreased (P < 0.001) with longer axial length., Conclusions: Beyond 26.0 mm of axial length, horizontal and vertical BMO diameter increased by 0.21 mm (95% CI: 0.16, 0.27) and 0.12 mm (95% CI: 0.06, 0.18), respectively, for each millimeter of axial elongation. Gamma zone may develop due to an axial elongation-associated BMO enlargement (β: 0.46) and, to a minor degree, a BMO shift in direction to the macula (β: 0.14). A large gamma zone may be protective against myopic macular BM defects.

Background: The prevalence of myopia has markedly increased, particularly in the young generations in East and Southeast Asia., Objective: The aim is to describe the epidemiology of myopia and the morphological alterations associated with myopia., Material and Methods: The results of epidemiological, clinical and histological studies are summarized., Results: During the last three decades the prevalence of myopia has markedly increased so that currently 80-90% of 18-years-olds in East Asia are myopic and 10-20% are highly myopic. It is estimated that by 2050 the frequency of myopia worldwide will increase to 50% and high myopia to ca. 10% and high myopia will become the most frequent cause of irreversible blindness due to the association with myopic maculopathy and glaucomatous optic nerve atrophy. Myopia is morphologically characterized by predominantly sagittal and to a lesser extent coronal enlargement of the eyeball. This results in retinal thinning and reduction in the density of the retinal pigment epithelium (RPE) in the equatorial region, thinning of the choroid and sclera mostly at the posterior pole, normal retinal thickness and RPE density in the macular region, normal thickness of Bruch's membrane (BM) in any region, elongated disc-fovea distance due to the development of parapapillary gamma and delta zones, enlargement and vertical rotation of the optic disc and elongation and thinning of the lamina cribrosa and peripapillary scleral flange., Discussion: These morphological alterations can possibly be explained by a new formation and elongation of the BM in the equatorial region leading to sagittal elongation of the eyeball.

Purpose: Because there is a paucity of population-based data on retinal nerve fiber layer thickness (RNFLT) for children, we measured the RNFLT and its associations in schoolchildren., Methods: The population-based Gobi Desert Children Eye Study included all schoolchildren aged 6 to 21 years living in Ejina, Inner Mongolia. The children underwent a comprehensive ocular examination with cycloplegic refractometry and spectral-domain optical coherence tomography of the optic nerve head. The peripapillary RNFLT was measured on the optical coherence tomography images of a circular scan with a diameter of 3.4 mm., Results: Out of 1565 participants, RNFLT data were available for 1440 (92.5%) children. The mean global RNFLT was 101.3 ± 9.2 μm in right eyes. The RNFLT was thickest in the temporal inferior sector (157.3 μm), followed by the temporal superior sector (143.8 μm), the nasal inferior sector (109.7 μm), the nasal superior sector (106.9 μm), temporal sector (85.2 μm), and the nasal sector (61.7 μm). In multivariate analysis, the RNFLT decreased with higher myopic refractive error (P < 0.001), male sex (P = 0.001), higher intraocular pressure (P = 0.002), and lower birth weight (P = 0.03). It was not significantly associated with age (P = 0.19), body mass index (P = 0.57), mean arterial blood pressure (P = 0.33), pulse rate (P = 0.28), and subfoveal choroidal thickness (P = 0.11)., Conclusions: The RNFLT in children showed a regional distribution, with the thickest part in the temporal inferior sector and the thinnest part located in the nasal sector. The overall RNLFT significantly decreased with higher myopic refractive error and male sex. In schoolchildren, in contrast to adults, the RNFLT did not decrease with older age. These findings may be considered when interpreting RNFLT data in children.

Purpose: Axial myopia is associated with elongation of the posterior ocular segment. The authors measured posterior fundus landmarks and assessed their associations with axial length., Methods: Using fundus photographs, the authors measured the vertical distance between the temporal superior and temporal inferior arterial arcade (VDA) and the angle kappa between the temporal arterial arcades among other morphometric variables., Results: The study included 456 eyes with a mean age of 61.2 ± 14.2 years (range: 13-88 years) and mean axial length of 29.4 ± 2.1 mm (range: 23.2-35.3 mm). Mean angle kappa was 91.3 ± 17.2° (range: 39-161°), and mean VDA was 7.93 ± 1.71 mm (range: 2.72-12.85 mm). In multivariate regression analysis, wider angle kappa was associated (regression coefficient r: 0.47) with shorter axial length (P = 0.002; beta: -0.17; B: -1.37; 95% confidence interval [CI]:-2.23 to -0.51), longer VDA (P < 0.001; beta: 0.27; B: 2.70; 95% CI: 1.85-3.54), shorter disk-foveola distance (P < 0.001; beta: -0.22; B: -4.76; 95% CI: -7.05 to -2.46), shorter vertical optic disk diameter (P = 0.002; beta: -0.14; B: -6.83; 95% CI: -11.1 to -2.56), lower number of any chorioretinal lesions (P = 0.007; beta: -0.13; B: -2.11; 95% CI: -3.63 to -0.58), and longer maximal vertical chorioretinal lesion diameter (P = 0.05; beta: 0.09; B: 0.92; 95% CI: -0.02 to 1.86). A longer VDA was associated (r: 0.31) with longer axial length (P < 0.001; beta: 0.22; B: 0.18; 95% CI: 0.10-0.25), wider angle kappa (P < 0.001; beta: 0.28; B: 0.03; 95% CI: 0.02-0.04) and higher number of chorioretinal lesions (P = 0.03; beta: 0.10; B: 0.16; 95% CI: 0.02-0.31). If eyes with chorioretinal lesions were excluded, the association between longer VDA and longer axial length was no longer statistically significant (P > 0.10)., Conclusion: Axial elongation was correlated with decreasing angle kappa, caused by an elongation of the disk-foveola distance because of an enlargement of the gamma zone, whereas VDA remained constant. By contrast, horizontal length of macular Bruch membrane and vertical length of macular Bruch membrane were independent of axial elongation. Axial elongation did not lead to lengthening of Bruch membrane in the macular region in eyes without macular chorioretinal lesions.

Purpose: To assess changes in the optic disc-fovea distance (DFD) with progressing myopia in school children., Methods: The school-based, prospective, longitudinal study included grade-1 children in 2011 who were yearly re-examined until 2016. We measured DFD, optic disc diameters and width of parapapillary gamma zone (parapapillary region without Bruch's membrane (BM)) on fundus photographs., Results: Of 382 grade-1 children examined in 2011, 294 (77.0%) children (mean age in 2011: 6.4 ± 0.5 years) returned to be examined in 2016. In relative terms, the increase in DFD (1.15 ± 0.33 mm) was more due to an increase in gamma zone width (+300% or 0.29 ± 0.30 mm) than an increase in macular BM length (+18% or 0.74 ± 0.21 mm). In multivariate regression analysis, longer increase in DFD was correlated (regression coefficient r 2  = 0.79) with longer axial elongation during the study period (p < 0.001; standardized regression coefficient β: 0.61; non-standardized regression coefficient B: 0.30; 95% confidence interval (CI): 0.26, 0.33), larger increase in gamma zone width (p < 0.001; β: 0.35; B: 0.40; 95%CI: 0.32, 0.48) and longer axial length in 2011 (p = 0.01; β:0.07; B:0.03; 95%CI:0.01, 0.06). Larger increase in gamma zone width was associated (r 2  = 0.73) with larger increase in DFD (p < 0.001; β: 0.51; B: 0.46; 95%CI: 0.39, 0.53), larger increase in the vertical-to-horizontal disc diameter ratio (p < 0.001; β: 0.43; B:1.21; 95%CI: 1.00, 1.42) and longer vertical disc diameter (p < 0.001; β: 0.15; B:0.24; 95%CI: 0.14, 0.34)., Conclusion: In adolescent school children, axial elongation-associated increase in DFD was mainly due to an enlargement (+300%) of parapapillary gamma zone, while macular BM length increased to minor degree (+18%). Gamma zone enlargement was correlated with axial elongation-associated vertical optic disc rotation, potentially due to an increased backward pull of the optic nerve on the temporal optic disc border., (© 2018 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To use finite element (FE) analysis to understand the origin of the ocular pulse and predict its biomechanical impact on the optic nerve head (ONH)., Methods: An FE model of a healthy eye was reconstructed. The choroid was biphasic and consisted of a solid phase (connective tissues) and a fluid phase (blood). We applied arterial blood pressure at 18 entry sites (posterior ciliary arteries) and venous blood pressure at 4 exit sites (vortex veins). For one cardiac cycle, we reported the resulting pulse volume, the ocular pulse amplitude (OPA), and diastole-to-systole ONH deformations. We also studied the effect of a change in scleral stiffness, in arterial pressure, and in baseline IOP., Results: During the cardiac cycle, a change in arterial pressure resulted in choroidal expansion, which in turn induced a change in IOP (the OPA) and ONH deformations. From diastole to systole, we found that choroidal expansion made the peripapillary retina move anteriorly, but both choroidal expansion and the OPA made the prelamina and LC move posteriorly. The net result was shearing of neural tissues in the neuroretinal rim. Both a stiffer sclera and a higher IOP resulted in a higher OPA, smaller pulse volume, larger diastole-to-systole ONH strains, and neural tissue shear in the neuroretinal rim. Increasing the arterial pressure had the same effect, except that it increased the pulse volume., Conclusions: Our models indicate that, during the cardiac cycle, the OPA and choroidal expansion can deform the ONH with a net shearing of neural tissues within the neuroretinal rim.

Purpose: To assess prevalence and size of the parapapillary beta zone and gamma zone in a healthy population., Methods: Within the population-based Beijing Eye Study, individuals without retinal or optic nerve disease were selected. Using optical coherence tomography (OCT), we measured the parapapillary beta zone (defined by presence of Bruch's membrane and absence of RPE) and gamma zone (region between Bruch's membrane end and optic disc border)., Results: The study included 723 individuals (mean age: 59.5 ± 7.6 years; range: 50-90 years). The beta zone was detected in 525 eyes (72.6%; 95% confidence interval [CI]: 69.4, 75.9). A larger maximum width of the beta zone (mean: 253 ± 225 μm) was associated (multivariate analysis; regression coefficient r2: 0.36) with older age (P < 0.001; standardized regression coefficient beta: 0.28), thinner temporal parapapillary choroidal thickness (P < 0.001; beta: -0.21), longer axial length (P < 0.001; beta: 0.14), longer vertical Bruch's membrane opening (BMO) length (P < 0.001; beta: 0.32), shorter horizontal BMO length (P = 0.003; beta: -0.12), and more pronounced vertical optic disc rotation of (P < 0.001; beta: 0.15). The gamma zone was detected in 190 eyes (26.3 ± 1.6%; 95% CI: 23.1, 29.5). A larger maximal width of the gamma zone (mean: 86 ± 187 μm) was (r2: 0.49) associated with longer axial length (P < 0.001; beta: 0.46), thinner central corneal thickness (P < 0.001; beta: 0.10), thinner temporal parapapillary choroidal thickness (P < 0.001; beta: -0.11), longer vertical (P < 0.001; beta: 0.15), and horizontal (P = 0.02; beta: 0.08) BMO length, and more pronounced vertical rotation of optic disc (P < 0.001; beta: 0.32)., Conclusions: As measured by OCT in this healthy adult Chinese population, the gamma zone was mainly associated with longer axial length but not with age, while the beta zone was correlated mainly with older age and also with axial length. Both zones were largest in the temporal parapapillary region and smallest in the nasal region.

Purpose: To evaluate whether automated assessment of beta zone parapapillary atrophy (βPPA) area can differentiate between glaucomatous and healthy eyes of varying axial lengths (AL)., Design: Cross-sectional study., Methods: βPPA was automatically identified in glaucoma and healthy eyes with enhanced-depth imaging optical coherence tomography (OCT) optic nerve head (ONH) radial B-scans. Associations with AL and the presence of glaucoma were assessed. Manually delineated βPPA on individual OCT ONH B-scans of 35 eyes from the Diagnostic Innovations in Glaucoma Study served to validate the automated method., Results: One hundred fifty-three glaucoma eyes (mean ± standard deviation) (visual field mean deviation, -5.0 ± 6.4 dB and mean AL, 25.1 ± 1.1 mm) and 73 healthy eyes (visual field mean deviation, 0.1 ± 1.4 dB and mean AL, 24.1 ± 1.1 mm) were included. In multivariable analysis, larger βPPA area was significantly associated with a diagnosis of glaucoma after controlling for age, central corneal thickness, and AL. Moreover, in multivariable analysis, the odds of having glaucoma were doubled for each 0.2 mm 2 larger βPPA area. The age- and AL-adjusted area under the receiver operating characteristic curve (95% confidence interval) of βPPA area for differentiating between glaucoma and healthy eyes was 0.75 (0.68-0.81). Agreement for the location of the Bruch membrane opening and the location of retinal pigment epithelium tips was stronger between the automated technique and each individual observer than it was between the 2 observers., Conclusions: Larger βPPA area, as determined by automated OCT assessment, is significantly associated with a diagnosis of glaucoma, even after adjusting for age and AL, and may aid in differentiating healthy from glaucomatous eyes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to measure the rupture pressure and the biomechanical properties of porcine Bruch's membrane (BM)-choroid complex (BMCC) and the influences of BM on optic nerve head (ONH) tissues., Methods: The biomechanical properties of BMCC were extracted through uniaxial tensile tests of 10 BMCC specimens from 10 porcine eyes; the rupture pressures of BMCC were measured through burst tests of 20 porcine eyes; and the influence of BM on IOP-induced ONH deformations were investigated using finite element (FE) analysis., Results: Uniaxial experimental results showed that the average elastic (tangent) moduli of BMCC samples at 0% and 5% strain were 1.60 ± 0.81 and 2.44 ± 1.02 MPa, respectively. Burst tests showed that, on average, BMCC could sustain an IOP of 82 mm Hg before rupture. FE simulation results predicted that, under elevated IOP, prelamina tissue strains increased with increasing BM stiffness. On the contrary, lamina cribrosa strains showed an opposite trend but the effects were small., Conclusions: BMCC stiffness is comparable or higher than those of other ocular tissues and can sustain a relatively high pressure before rupture. Additionally, BM may have a nonnegligible influence on IOP-induced ONH deformations.

Purpose: To examine parapapillary zones gamma and delta in highly myopic eyes., Methods: The retrospective observational study included patients attending the Tokyo high myopia clinics. Fundus photographs were morphometrically examined., Results: The study population included 600 eyes (304 individuals) with a mean age of 62.7 ± 14.3 years (range: 13-90 years) and mean axial length of 29.6 ± 2.2 mm (range: 23.2-35.4 mm). In multivariate analysis (regression coefficient r:0.90), larger horizontal gamma zone diameter was correlated with wider delta zone diameter (P < 0.001; standardized regression coefficient beta: 0.81), higher ratio of vertical-to-horizontal disk diameter (P < 0.001; beta: 0.10), shorter fovea-outer gamma zone border distance (P < 0.001; beta: -0.19), longer disk-fovea distance (P < 0.001; beta: 0.18), and higher count of chorioretinal atrophic lesions (P < 0.001; beta: 0.07). Longer horizontal delta zone width was correlated with longer horizontal gamma zone diameter (P < 0.001; beta: 1.00), longer horizontal disk diameter (P < 0.001; beta: 0.15), shorter disk-fovea distance (P < 0.001; beta: -0.19), longer fovea-outer gamma zone border distance (P < 0.001; beta: 0.19), and smaller diameter of the largest chorioretinal lesion (P = 0.03; beta: -0.04). Longer width of both zones together was associated with longer horizontal disk diameter (P < 0.001; beta: 0.31), higher ratio of vertical-to-horizontal disk diameter (P = 0.001; beta: 0.18), longer disk-fovea distance (P < 0.001; beta: 0.19), shorter fovea-outer gamma zone border distance (P < 0.001; beta: -0.18), higher number of chorioretinal lesions (P < 0.001; beta: 0.30), and longer vertical distance between the superior and inferior temporal arterial arcade (P = 0.001; beta: 0.13)., Conclusion: Larger gamma and delta zones were correlated with larger optic disk and more marked vertical optic disk rotation, longer disk-fovea distance, higher number of chorioretinal lesions, and longer temporal vascular arcade diameter. Parapapillary gamma and delta zones may develop before chorioretinal lesions develop and enlarge.

To investigate changes in retinal vessel density in optic nerve head (ONH) and macula after acute intraocular pressure (IOP) elevation, we conducted a prospective observational study. Eyes with IOP rise ≥5 mmHg after 2-hour dark room prone provocative test (DRPPT) were included. Vasculature of ONH and macula was examined by optical coherence tomography angiography (OCTA) at baseline and after DRPPT. Among the 65 eyes of 42 individuals, 40 eyes with qualified images were enrolled. Mean IOP rise was 9.6 ± 4.2 mmHg (5.0-23.3 mmHg) after DRPPT. Retinal vessel density did not differ after IOP rise for either the papillary region (optic nerve head and radial peripapillary capillary layer) or the macula region (superficial, deep and outer retinal layer) (P > 0.05). Vessel density in each subregion did not change either. If only enrolled eyes with IOP rise ≥10 mmHg, similar results were obtained in condition of IOP increase by 15.0 ± 3.6 mmHg. To conclude, eyes with an acute IOP elevation by 10 or 15 mmHg for two hours, while the blood pressure remained constant, the vessel density in both ONH and macula region examined by OCTA did not show significant changes. The observations fit with an IOP-related autoregulation in retinal blood flow for a moderate elevation of IOP.

Purpose: To assess the development and enlargement of the parapapillary gamma zone in school children., Methods: This school-based prospective longitudinal study included Chinese children attending grade 1 in 2011 and returning for yearly follow-up examinations until 2016. These examinations consisted of a comprehensive ocular examination with biometry and color fundus photographs. The parents underwent a standardized interview. The parapapillary gamma zone was defined as the area with visible sclera at the temporal optic disc margin, and the optic disc itself was measured on fundus photographs., Results: The study included 294 children (mean age in 2016, 11.4 ± 0.5 years [range, 10-13 years]; mean axial length, 24.1 ± 1.1 mm [range, 21.13-27.29 mm]). In multivariate analysis, larger increases in the gamma zone area during the study period were correlated (coefficient of determination for bivariate analysis [r2], r2 = 0.69) with larger increases in the vertical-to-horizontal disc diameter ratios (P < 0.001; standardized regression coefficient beta [beta], 0.53; nonstandardized regression coefficient B [B], 4.05; 95% confidence intervals [CI], 3.37-4.73), larger axial elongation (P < 0.001; beta, 0.32; B, 0.37; 95% CI, 0.26-0.47), a larger vertical disc diameter at baseline (P < 0.001; beta, 0.22; B, 0.98; 95% CI, 0.62-1.33), a larger gamma zone area at baseline (P < 0.001; beta, 0.14; B, 0.41; 95% CI, 0.17-0.64), and more time spent indoors studying (P = 0.015; beta, 0.10; B, 0.09; 95% CI, 0.02-0.17)., Conclusions: The development and enlargement of the gamma zone in the temporal parapapillary region were associated with an optic disc rotation around the vertical disc axis as indicated by an increasing vertical-to-horizontal disc diameter ratio. These morphologic findings fit with the notion of a backward pull of the temporal peripapillary sclera through the optic nerve dura mater in axially elongated eyes.

Purpose: To describe the occurrence of a congenital contractile peripapillary staphyloma in association with a rhegmatogenous retinal detachment., Methods: The clinical course of a 17-year-old patient with a contractile peripapillary staphyloma and undergoing pars plana vitrectomy for repair of an associated retinal detachment was studied., Results: The left eye showed a peripapillary staphyloma which during the ophthalmoscopical examination revealed contractile movements after the presentation of a light stimulus to either eye. The contraction of the peripapillary staphyloma was not correlated with a Valsalva maneuver, neck venous compression, forced lid closure, or respiratory movements. Because of a retinal detachment involving the inferior, nasal, and temporal retina, best-corrected visual acuity was 20/100. During pars plana vitrectomy under systemic anesthesia, the contractions of the peripapillary staphyloma subsided in the early phase of surgery, and reoccurred at approximately 80 minutes after the start of general anesthesia, when the posterior pole was touched with an aspiration syringe., Conclusion: The etiology of the movements of the congenital peripapillary staphyloma in our patient may include a misbalance between intraocular pressure and orbital cerebrospinal fluid pressure or contractions of extraocular muscles. The observations may give information about the physiology and pathophysiology of the optic nerve head.

Purpose: To examine the association between intraocular pressure (IOP) and the prevalence of glaucomatous optic neuropathy (GON) in high myopia., Methods: The hospital-based observational study consisted of patients treated in the Tokyo High Myopia Clinics and for whom fundus photographs and IOP readings were available. The appearance of the optic nerve head on fundus photographs was the basis for the definition of GON., Results: Among 517 eyes of 261 patients (mean age: 62.1 ± 14.2 years; range: 13-89 years; mean axial length: 29.5 ± 2.2 mm; range: 23.2-35.3 mm), GON was present in 141 eyes (27.3%; 95% confidence intervals [CIs]: 23.4, 31.0). Mean IOP did not differ significantly (P = 0.53) between the glaucoma group (14.5 ± 3.3 mm Hg; median: 14 mm Hg; range: 8-38 mm Hg) and the nonglaucomatous group (14.7 ± 2.5 mm Hg; median: 14 mm Hg; range: 6-23 mm Hg). In eyes with an axial length of ≤27.4 mm, higher presence of GON was correlated only with higher IOP (P = 0.037; odds ratio [OR]:1.35; 95% CI: 1.02, 1.80). In eyes with an axial length of ≥27.5 mm, presence of GON was correlated with older age (P < 0.001; OR: 1.05; 95% CI :1.03, 1.08), longer axial length (P < 0.001; OR: 1.60; 95% CI: 1.34, 1.91), shorter vertical diameter of the temporal arterial arcade (P = 0.009; OR: 0.82; 95% CI: 0.71, 0.95), and longer minimal optic disc diameter (P = 0.002; OR: 3.07; 95% CI: 1.52, 6.21). If IOP was added to the model, it was not significantly associated with the prevalence of GON (P = 0.97; OR: 1.00; 95% CI: 0.91, 1.10)., Conclusions: GON was associated with elevated IOP in myopic eyes with an axial length of ≤27.4 mm, while in more highly myopic eyes (axial length ≥27.5 mm), larger optic disc, longer axial elongation and older age-but not IOP mostly within its normal range-were factors associated with GON. Future studies may examine an abnormally low IOP to be associated with a lower GON prevalence in highly myopic eyes.

Purpose: To assess thickness and associations of the peripapillary choroidal layers., Methods: The population-based Beijing Eye Study included 3468 participants with an age of 50+ years. Using spectral-domain optical coherence tomography, we measured the large vessel layer (LVL) and small-to-medium vessel layer (SMVL) of the peripapillary choroid in a circular scan with a diameter of 3.4 mm around the optic nerve head centre at eight locations equidistant (45°) to each other. The ratio of SMVL thickness to LVL thickness was calculated., Results: Measurements were available for 3000 (86.5%) study participants (mean age: 64.4 ± 9.6 years; range: 50-93 years). SMVL (mean thickness: 31 ± 7 μm; range: 17-70 μm) and LVL (103 ± 48 μm; range: 9-313 μm) were thickest superiorly, followed by the temporal region, nasal region, and inferior region. Thicker SMVL was associated (regression coefficient r: 0.33) with younger age (p < 0.001; standardized regression coefficient β: -0.26), higher cognitive function (p = 0.02; β: 0.05), shorter axial length (p < 0.001; β: -0.12), thicker lens (p < 0.001; β: 0.07), smaller disc area (p < 0.001; β: -0.08), smaller parapapillary β/γ zone (p < 0.001; β: -0.10) and lower prevalence of angle-closure glaucoma (p = 0.04; β: -0.04). Thicker LVL thickness was correlated (r: 0.45) with younger age (p < 0.001; β: -0.34) and higher cognitive function (p = 0.01; β: 0.05), shorter axial length (p < 0.001; β: -0.09)), thicker lens (p = 0.009; β: 0.06), smaller disc area (p < 0.001; β: -0.09), smaller parapapillary alpha zone (p = 0.04; β: -0.04), smaller β/γ zone (p < 0.001; β: -0.14) and lower prevalence of angle-closure glaucoma (p = 0.057; β: -0.04). A higher SMVL-to-LVL thickness ratio was related with older age (p < 0.001; β: 0.36), longer axial length (p < 0.001; β: 0.09), lower best-corrected visual acuity (BCVA) (p = 0.002; β: 0.07), larger optic disc area (p < 0.001; β: 0.10) and larger β/γ zone (p < 0.001; β: 0.19)., Conclusion: Small-to-medium vessel layer (SMVL) and LVL, thickest superiorly and thinnest inferiorly, increased with younger age and higher cognitive function after adjusting for axial length and prevalence of angle-closure glaucoma. With older age, longer axial length, larger optic disc area and larger β zone, LVL decreased more than SMVL in thickness. The association between thicker peripapillary choroidal thickness and better cognitive function may deserve further attention., (© 2017 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To measure the optic disc rotation around the vertical and horizontal disc axis and to evaluate associations with general and ocular parameters., Design: Population-based study., Methods: In the Beijing Eye Study, 3468 participants (mean age:64.6±9.8 years; range:50-93 years) underwent an ophthalmological examination which included spectral-domain optical coherence tomography (OCT) with enhanced depth imaging. Using the OCT images, we determined the amount of the rotation of the optic disc (defined as Bruch´s membrane opening (BMO)) around the vertical axis and horizontal axis., Results: Optic disc rotation measurements were available for 3037 (87.6%) individuals. In multivariate analysis, larger optic disc rotation around the vertical axis (range:-4.90° to 41.0°) was associated (regression coefficient r:0.27) with high axial myopia (axial length ≥26.5 mm) (P<0.001;standardized regression coefficient beta beta:0.09), longer disc-fovea distance (P = 0.001;beta:0.09) and wider parapapillary beta/gamma zone (P<0.001;beta0.12). Larger optic disc rotation around the horizontal axis (range:-7.10° to 26.4°) was associated (r:0.32) with high axial myopia (P = 0.001;beta:0.08), larger optic disc-fovea angle (P<0.001;beta:0.13), thinner superior nasal retinal nerve fiber layer (RNFL) thickness (P<0.001;beta:-0.19) and thicker inferior nasal RNFL thickness (P<0.001;beta:0.17)., Conclusions: Vertical optic disc rotation was associated with highly myopic axial elongation, increased disc-fovea distance and development or enlargement of parapapillary, Bruch´s membrane free, gamma zone, while macular Bruch´s membrane length is not affected. Horizontal optic disc rotation was associated with inferior dislocation of the fovea, in addition to a thinner superior nasal RNFL and thicker inferior nasal RNFL. The latter association may be taken into account in the interpretation of RNFL thickness profiles.

Purpose: Interindividual variance in optic nerve head (ONH) position, axial length, and location of the temporal raphe suggest that customizing mapping between visual field locations and ONH sectors for individuals may be clinically useful. Herein we quantify the proportion of the population predicted to have structure-function mappings that markedly deviate from "average," and thus would benefit from customized mapping., Design: Database study and case report., Participants: Population database of 2836 eyes from the Beijing Eye Study and a single case report of an individual with primary open-angle glaucoma., Methods: Using the morphometric fundus data of the Beijing Eye Study for 2836 eyes and applying a recently developed model based on axial length and ONH position relative to the fovea, we determined for each measurement location in the 24-2 Humphrey (Carl Zeiss Meditec, Dublin, CA) visual field the proportion of eyes for which, in the customized approach as compared with the generalized approach, the mapped ONH sector was shifted into a different sector. We determined the proportion of eyes for which the mapped ONH location was shifted by more than 15°, 30°, or 60°., Main Outcome Measures: Mapping correspondence between locations in visual field space to localized sectors on the ONH., Results: The largest interindividual differences in mapping are in the nasal step region, where the same visual field location can map to either the superior or inferior ONH, depending on other anatomic features. For these visual field locations, approximately 12% of eyes showed a mapping opposite to conventional expectations., Conclusions: Anatomically customized mapping shifts the map markedly in approximately 12% of the general population in the nasal step region, where visual field locations can map to the opposite pole of the ONH than conventionally considered. Early glaucomatous damage commonly affects this region; hence, individually matching structure to function may prove clinically useful for the diagnosis and monitoring of progression within individuals., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To use finite element (FE) analysis to predict the optic nerve sheath traction forces that act on the optic nerve head (ONH) following horizontal eye movements, and the resulting stress levels in the peripapillary connective tissues of the ONH (Bruch's membrane [BM] and sclera)., Methods: An FE model of a healthy eye was reconstructed in primary gaze position that included details from the orbital and ONH tissues. Optic nerve sheath traction forces and peripapillary tissue stresses in both adduction and abduction (13°) were computed using FE analysis., Results: Our models predicted that, following eye movements, the ONH was sheared in the transverse plane due to the pulling action of the optic nerve. The optic nerve sheath traction forces were 90 mN in abduction and 150 mN in adduction. Peripapillary tissue stresses were concentrated in the nasal and temporal quadrants. In adduction, scleral stresses were highest in the temporal region, and BM stresses were slightly higher in the nasal region. This trend was reversed in abduction., Conclusions: Following eye movements, our models predicted high optic nerve sheath traction forces of the same order of magnitude as extraocular muscle forces. Optic nerve traction resulted in significant peripapillary stresses, and thus may have a role to play in the development of peripapillary zones, glaucoma, and myopia.