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Pathologic myopia is a severe form of myopia that can lead to permanent visual impairment. The recent global increase in the prevalence of myopia has been projected to lead to a higher incidence of pathologic myopia in the future. Thus, imaging myopic eyes to detect early pathological changes, or predict myopia progression to allow for early intervention, has become a key priority. Recent advances in optical coherence tomography (OCT) have contributed to the new grading system for myopic maculopathy and myopic traction maculopathy, which may improve phenotyping and thus, clinical management. Widefield fundus and OCT imaging has improved the detection of posterior staphyloma. Non-invasive OCT angiography has enabled depth-resolved imaging for myopic choroidal neovascularisation. Artificial intelligence (AI) has shown great performance in detecting pathologic myopia and the identification of myopia-associated complications. These advances in imaging with adjunctive AI analysis may lead to improvements in monitoring disease progression or guiding treatments. In this review, we provide an update on the classification of pathologic myopia, how imaging has improved clinical evaluation and management of myopia-associated complications, and the recent development of AI algorithms to aid the detection and classification of pathologic myopia.

To evaluate the interrelationship between macular sensitivity and retinal perfusion density (PD) in eyes with myopic macular degeneration (MMD).One hundred and thirty-eight highly myopic eyes from 82 adult participants were recruited. Macular sensitivity was evaluated using the Microperimeter MP-3. Retinal PD was measured using the PLEX Elite 9000 swept source optical coherence tomography angiography. Macular sensitivity values between different categories of MMD and its relationship with optical coherence tomography angiography measurements were evaluated using multivariable linear mixed models, adjusting for age and axial length.Macular sensitivity reduced with increasing severity of MMD (β ≤ -0.95, P0.001), whereas the best-corrected visual acuity was not associated with MMD severity (P0.04). Persons who were older (β = -0.08, P0.001), with longer axial length (β = -0.32, P = 0.005), presence of macular diffuse choroidal atrophy (β = -2.16, P0.001) or worse MMD (β = -5.70, P0.001), and presence of macular posterior staphyloma (β ≤ -2.98, P0.001) or Fuchs spot (β = -1.58, P = 0.04) were associated with reduced macular sensitivity. Macular sensitivity was significantly associated with deep retinal PD in MMD (β = 0.15, P = 0.004) but not with superficial retinal PD (P = 0.62).There was a strong correlation between reduced macular sensitivity and increasing MMD severity, even in mild MMD independent of the best-corrected visual acuity. Furthermore, macular sensitivity was correlated with deep retinal PD, suggesting a vasculature-function relationship in MMD.

Xian Hui Lim,1 Monisha Esther Nongpiur,1– 3 Raymond P Najjar,2,3 Quan V Hoang,1– 4 Dan Milea,1– 3 Chee Wai Wong,1– 3 Rahat Husain,1,3 Hla Myint Htoon,2,3 Tin Aung,1– 3,5 Shamira Perera,1– 3 Tina Tzee Ling Wong1– 3,5 1Singapore National Eye Centre, Singapore; 2Singapore Eye Research Institute, Singapore; 3Duke-NUS Medical School, Singapore; 4Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia College of Physicians and Surgeons, New York, NY, USA; 5Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, SingaporeCorrespondence: Tina Tzee Ling WongSingapore National Eye Centre, 11 Third Hospital Avenue, 168751, SingaporeEmail tina.wong.t.l@singhealth.com.sgPurpose: To investigate features of the steady-state pattern electroretinogram (ssPERG) in subjects with glaucoma (G), high myopia (HM; spherical equivalent ≤-6D) and glaucoma with high myopia (GHM).Patients and Methods: Our study included 48 participants divided into 3 groups (G, HM, and GHM) who each underwent monocular ssPERG testing with Diopsys NOVA PERG protocols. The ConStim protocol detects distinct topographic patterns of dysfunction 16° and 24° around the central macula. MagD is the amplitude of the average signal and MagD/Mag ratio indicates the consistency of the response. ssPERG indices were compared between groups and correlated with functional (ie, visual field mean deviation (VFMD)) and structural (ie, average retinal nerve fibre layer (RNFL) thickness; Cirrus optical coherence tomography) features.Results: Participants had an average age of 59.4± 7.6 years. Mean Humphrey VFMD was − 14.22 ± 2.88dB, − 2.62 ± 1.18dB and − 12.80 ± 2.60dB for G, HM and GHM groups, respectively. Mean RNFL thickness was 63.0 ± 8.20μm, 69.5 ± 15.7μm and 60.6 ± 5.0μm for G, HM and GHM groups, respectively. For the 24° setting, no significant differences were noted for any of the parameters. For the 16° setting, MagD was lower in the GHM group compared to the HM group (0.29μV vs 0.52μV; p = 0.02). Significant differences were noted for the MagD/Mag ratio between HM and G groups (0.58 vs 0.40; p = 0.02) and between HM and GHM groups (0.58 vs 0.35; p = 0.002). There were positive correlations between both MagD 16° and MagD/Mag ratio 16° with VFMD (correlation coefficient [r]=0.37, p = 0.009; and r = 0.44, p = 0.002, respectively) and RNFL (r = 0.43, p = 0.002; and r = 0.48, p = 0.001, respectively).Conclusion: MagD/Mag ratio at 16° was significantly lower in glaucomatous eyes (with or without high myopia) compared to those with high myopia without glaucoma, suggesting that glaucoma has a distinct impact on MagD/Mag ratio at 16° irrespective of the presence of myopia.Keywords: pattern electroretinogram, visual field mean deviation, optical coherence tomography, retinal nerve fibre layer

AimsTo characterise the association between visual field (VF) defects and myopic macular degeneration (MMD) in highly myopic adults without glaucoma.MethodsParticipants (n=106; 181 eyes) with high myopia (HM; spherical equivalent ≤−5.0 D or axial length (AL) ≥26 mm), after excluding glaucoma and glaucoma suspects, from the Singapore Epidemiology of Eye Diseases-HM study were included in this cross-sectional study. Humphrey VF (central 24–2 threshold), cup-disc ratio (CDR) and intraocular pressure (IOP) measurements were performed. Mean deviation (MD) and pattern SD (PSD), VF defects (normal or abnormal; pResultsMean age was 55.4±9.9 years and 51.9% were women (AL=26.7±1.1 mm). MMD eyes had lower MD (−3.8±2.9 dB vs −1.1±1.4 dB) and higher PSD (2.8±1.7 dB vs 1.7±0.6 dB). A higher percentage of MMD eyes (n=48) had abnormal VF (62.5% vs 28.6%; pConclusionHighly myopic adults with MMD may have VF loss when compared with highly myopic patients without MMD even in adults without glaucoma.

Purpose To review the impact of increased digital device usage arising from lockdown measures instituted during the COVID-19 pandemic on myopia and to make recommendations for mitigating potential detrimental effects on myopia control. Design Perspective. Methods We reviewed studies focused on digital device usage, near work, and outdoor time in relation to myopia onset and progression. Public health policies on myopia control, recommendations on screen time, and information pertaining to the impact of COVID-19 on increased digital device use were presented. Recommendations to minimize the impact of the pandemic on myopia onset and progression in children were made. Results Increased digital screen time, near work, and limited outdoor activities were found to be associated with the onset and progression of myopia, and could potentially be aggravated during and beyond the COVID-19 pandemic outbreak period. While school closures may be short-lived, increased access to, adoption of, and dependence on digital devices could have a long-term negative impact on childhood development. Raising awareness among parents, children, and government agencies is key to mitigating myopigenic behaviors that may become entrenched during this period. Conclusion While it is important to adopt critical measures to slow or halt the spread of COVID-19, close collaboration between parents, schools, and ministries is necessary to assess and mitigate the long-term collateral impact of COVID-19 on myopia control policies.

The production of nanofibrous materials for soft tissue repair that resemble extracellular matrices (ECMs) is challenging. Electrospinning uniquely produces scaffolds resembling the ultrastructure of natural ECMs. Herein, electrospinning was used to fabricate Bombyx mori silk fibroin (SF) and SF/halloysite nanotube (HNT) composite scaffolds. Different HNT loadings were examined, but 1 wt% HNTs enhanced scaffold hydrophilicity and water uptake capacity without loss of mechanical strength. The inclusion of 1 wt% HNTs in SF scaffolds also increased the scaffold’s thermal stability without altering the molecular structure of the SF, as revealed by thermogravimetric analyses and Fourier transform infrared spectroscopy (FTIR), respectively. SF/HNT 1 wt% composite scaffolds better supported the viability and spreading of 3T3 fibroblasts and the differentiation of C2C12 myoblasts into aligned myotubes. These scaffolds coated with decellularised ECM from 3T3 cells or primary human dermal fibroblasts (HDFs) supported the growth of primary human keratinocytes. However, SF/HNT 1 wt% composite scaffolds with HDF-derived ECM provided the best microenvironment, as on these, keratinocytes formed intact monolayers with an undifferentiated, basal cell phenotype. Our data indicate the merits of SF/HNT 1 wt% composite scaffolds for applications in soft tissue repair and the expansion of primary human keratinocytes for skin regeneration.

Aim The aim of this study is to evaluate the frequency and types of anti-retinal autoantibodies (ARAs) in highly myopic patients and to explore any association between ARAs and the severity of myopic macular degeneration (MMD). Methods This was a clinic-based study of 16 patients with high myopia (spherical equivalent worse than -6 dioptres or axial length (AL) ≥ 26.5 mm) recruited from the High Myopia clinic of the Singapore National Eye Centre. MMD was graded from fundus photographs according to the Meta-analysis for Pathologic Myopia (META-PM) classification. Severe MMD was defined as META-PM category 3 or 4. AL and logarithm of the minimal angle of resolution (logMAR) best corrected visual acuity (BCVA) were measured. Sera were obtained from subjects and analysed for the presence of ARAs with the western blot technique. Results The mean AL was significantly longer in patients with severe MMD (n = 8) than those without severe MMD (n = 8) (31.50 vs. 28.51, p = 0.005). There was at least one ARA identified in all patients. The most common ARA was anti-carbonic anhydrase II (anti-CAII), present in nine patients (56.3%). Anti-CAII was detected in more patients with severe MMD than those without (75 vs. 37.5%, p = 0.32). LogMar BCVA was also worse in subjects with anti-CAII (0.5 ± 0.38 vs. 0.22 ± 0.08, p = 0.06). The number of ARAs significantly correlated with increasing AL (r = 0.61, p = 0.012). Conclusions ARAs are prevalent in patients with high myopia, and this increases with increasing AL. In particular, anti-CAII antibodies were highly prevalent in patients with severe MMD, suggesting that ARAs may be associated with MMD. Further studies are necessary to confirm these observations in larger cohorts.

Purpose The aim of the study is to examine the baseline intraocular pressure (IOP) and its changes after performing a water drinking test (WDT) in patients with unilateral hemifacial spasm (HFS). Patients and methods In this prospective observational study, patients aged 21 years and above diagnosed with unilateral HFS were recruited from the Singapore National Eye Centre between January 2015 and August 2016. The unaffected eye of each patient served as a matched control. An interviewer-administered standardized questionnaire on HFS symptoms and ophthalmic examination was performed. Automated perimetry, optical coherence tomography (OCT) of the optic nerve head, color disc stereophotography and water drinking test (WDT) were done. The primary outcome measure was the difference in IOP between eyes affected by HFS and fellow eyes at baseline and at 15, 30 and 45 minutes of the WDT. Results Fifty-four patients with unilateral HFS were included. Mean age was 59.8±9.9 years (range, 37.0-84.0). Of these, 54% were female and 94% were Chinese. Mean baseline IOP was significantly higher in eyes with HFS (13.9±3.1mmHg) compared to fellow eyes (13.3±2.8mmHg) (p=0.008). There was no significant difference in absolute or percentage change in IOP from baseline between the 2 groups at 15, 30 and 45 minutes of the WDT. Mean vertical cup-disc ratio (VCDR) on clinical examination was significantly higher in eyes with HFS (0.5±0.2) compared to fellow eyes (0.4±0.2) (p=0.02). There was no significant difference between the groups for visual field parameters and mean retinal nerve fiber layer thickness on OCT. Conclusion Hemifacial spasm is associated with a small but significant difference in mean baseline IOP and VCDR between affected and fellow eyes. However, when eyes affected by HFS and fellow eyes were challenged with the WDT, both responded in similar ways.

To describe ophthalmology training experiences across the Asia-Pacific (APAC).Survey study.We utilized an anonymous online survey, which was previously validated and conducted in Europe, through Young Ophthalmologist leaders from the national member societies of the Asia-Pacific Academy of Ophthalmology (APAO) from September 2019 to July 2021. Responses were based on a 5-point Likert scale (where applicable) and data were analyzed using Microsoft Excel. Our main outcome measures were differences between regions, that is, Southeast Asia (SEA) and Western Pacific (WP); and seniority, that is, trainees/junior ophthalmologists and senior ophthalmologists.We collated 130 responses representing 20 regions in the APAC region. The year of completion of ophthalmic training ranged from 1999 to 2024. The mean duration of training was 3.7±1.0 years. Most (98/130, 75%) indicated an interest for a common training standard across the APAC. Comparing SEA and WP trainees, both regions had similar working environments, but those in SEA reported significantly lower remuneration than their counterparts in WP ($600 vs $3000, P0.05). WP trainees performed more phacoemulsification surgeries (76 WP vs 19 SEA), while SEA trainees conducted more manual small incision cataract surgeries (157 WP vs 1.5 SEA per duration of training). Senior ophthalmologists performed more cataract surgeries (210.9 senior ophthalmologists vs 40.1 junior ophthalmologists). Trainees had less confidence in medical competency areas such as interpreting an electroretinogram/visual evoked potential/electrooculogram (SEA=1.8, WP=2.1) and conducting an angiography (SEA=2.8, WP=3.4).Our study highlighted heterogeneity among ophthalmology training experiences in the APAC region, with the majority indicating an interest in a common training standard.

Purpose: To assess the effect of axial length (AL) on the prevalence of pathologic myopia (PM) and associated myopic features in a Singaporean hospital-based cohort of patient with high myopia (HM).Methods: In total, 923 HM eyes from 495 individuals were recruited from the Myopic and Pathologic Eyes in Singapore (MyoPES) cohort and underwent ocular biometry, fundus photography, fundus autofluorescence, and swept-source optical coherence tomography (SS-OCT). Images were analyzed for the presence of myopic macular degeneration (MMD), myopic choroidal neovascularization (mCNV), myopic traction maculopathy (MTM), peripapillary atrophy (PPA), myopic tilted disc, posterior staphyloma (PS), dome-shaped macula (DSM), vitremacular adhesions (VMA), and the epiretinal membrane (ERM). Eyes were stratified into quartiles based on ALs to determine cut-off values to perform comparisons between shorter-length and longer-length groups. A χ2-test was done to determine the difference in the prevalence of pathologies between groups.Results: Overall, mean AL was 29.2 ± 2.2 mm (range 25.0–36.7 mm). Myopic macular degeneration, PPA, myopic tilted disc, and ERM have AL threshold of ≥27.5 mm, whereas MTM has an AL threshold of ≥29.0 mm. We found that there was a significantly higher prevalence of MMD (88.2 vs. 49.4%; p < 0.001), PPA (98.1 vs. 80.1%; p < 0.001), myopic tilted disc (72.7 vs. 50.2%; p < 0.001), and ERM (81.4 vs. 17.3%; p = 0.003) in eyes with AL ≥ 27.5 mm vs. eyes without AL p < 0.001), mCNV (17.4 vs. 12.1%; p = 0.03), PS (43.4 vs. 34.7%; p = 0.012), DSM (21.3 vs. 13.2%; p = 0.002), and VMA (5.9 vs. 2.6%; p = 0.014) in eyes with AL ≥ 29.0 mm compared with AL < 29.0 mm.Conclusion: Our study describes the overall prevalence of PM and related pathologies among patients with HM in our hospital-based cohort. Longer eyes even among HM eyes had a significantly higher prevalence of PM-associated pathologies studied. This supports the premise that eyes with longer AL, even among HM eyes may be at greater risk of vision-threatening changes and therefore merit regular follow-up.

To determine the prevalence and characteristics of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) in eyes with patchy atrophy because of pathologic myopia.Five hundred eyes of 253 patients with patchy atrophy were examined between 2014 and 2020 at the Advanced Clinical Center for Myopia. The main outcome measures included the prevalence and characteristics of active MFC/PIC lesions diagnosed by optical coherence tomography.Fifty-five of the 500 eyes (11%) diagnosed with patchy atrophy had optical coherence tomography features of active MFC/PIC lesions, such as focal elevations of the retinal pigment epithelium filled with medium hyperreflectivity material, curvilinear scars (Schlaegel lines), and/or areas of outer retinal atrophy. At the time when the MFC/PIC was diagnosed, the mean age was 57.3 ± 12.0 years, and the mean axial length was 29.2 ± 1.8 mm. Macular neovascularization was found in 45 of eyes (81.8%) with MFC/PIC versus 151 eyes without such findings (33.9%; P0.001). In 25 of the 55 eyes (45.5%), active MFC/PIC lesions were found before the development of the patchy atrophy. The Bruch membrane defects were colocated with these lesions.Active MFC/PIC lesions were identified in a minority of eyes with pathologic myopia, and a subset of these lesions were observed to progress to findings indistinguishable from myopic patchy atrophy. Evidence of MFC/PIC in eyes with pathologic myopia appeared to be a risk factor for the development of macular neovascularization.

Myopia is one of the leading causes of visual impairment globally. Despite increasing prevalence and incidence, the associated cost of treatment remains unclear. Health care spending is a major concern in many countries and understanding the cost of myopia correction is the first step eluding to the overall cost of myopia treatment. As cost of treatment will reduce the burden of cost of illness, this will aid in future cost-benefit analysis and the allocation of healthcare resources, including considerations in integrating eye care (refractive correction with spectacles) into universal health coverage (UHC). We performed a systematic review to determine the economic costs of myopia correction. However, there were few studies for direct comparison. Costs related to myopia correction were mainly direct with few indirect costs. Annual prevalence-based direct costs for myopia ranged from $14-26 (USA), $56 (Iran) and $199 (Singapore) per capita, respectively (population: 274.63 million, 75.15 million and 3.79 million, respectively). Annually, the direct costs of contact lens were $198.30-$378.10 while spectacles and refractive surgeries were $342.50 and $19.10, respectively. This review provides an insight to the cost of myopia correction. Myopia costs are high from nation-wide perspectives because of the high prevalence of myopia, with contact lenses being the more expensive option. Without further interventions, the burden of illness of myopia will increase substantially with the projected increase in prevalence worldwide. Future studies will be necessary to generate more homogenous cost data and provide a complete picture of the global economic cost of myopia.

Purpose To evaluate the clinical characteristics and surgical outcomes of pediatric retinal detachments (RDs) in an Asian population. Methods Retrospective review of 171 eyes of 152 pediatric patients with rhegmatogenous RD over a 20-year period. Results Myopia was the most common risk factor in our population. At 6 months, primary anatomical success was 60.7%, and overall anatomical success was 86.7%. A total of 46.8% had best-corrected visual acuity of 20/40 or better, and 81.6% had best-corrected visual acuity of 20/200 or better. In primary RDs, high myopia (≤-6D) patients had a lower primary anatomical success compared to patients with moderate myopia (≤-2D) (59.3 vs. 100% P = 0.03). Increasing age and absence of proliferative vitreoretinopathy were associated with anatomical and visual success. Pars plana vitrectomy as the primary procedure was associated with decreased odds of anatomical success. A longer duration of symptoms, cataract, and a larger RD extent were associated with poorer functional outcome. Conclusion Myopia was the commonest risk factor for pediatric RD in our population. Good anatomical and functional outcome can be achieved with surgery. Increasing age at presentation and absence of proliferative vitreoretinopathy was associated with anatomical and functional success. High myopia was associated with poorer anatomical and functional outcome.

Inhibitors of vascular endothelial growth factors are used to treat a myriad of retinal conditions, including exudative age-related macular degeneration (AMD), diabetic macular oedema (DME) and diabetic retinopathy. Although effective, long-term efficacy is limited by the need for frequent and invasive intravitreal injections. The quest for sustained action therapeutics that can be delivered to target tissue in the least invasive manner is an arduous endeavour that has ended in premature failure for several technologies in Phase II or III trials. Nevertheless, there have been promising preclinical studies, and more are on the horizon: port delivery systems for the treatment of exudative AMD have entered Phase III trials and a wide array of preclinical studies have demonstrated the potential for nanoparticles, such as liposomes, dendrimers and cell penetrating peptides to deliver therapeutics into the posterior segment via minimally invasive routes. In this review, we discuss the challenges posed by ocular barriers for drug penetration and present the recent advancements of the most pertinent drug delivery platforms with a focus on the treatment of exudative AMD and DME.

Ocular drug delivery remains a unique challenge due to the barriers to drug penetration in the eye. Nanomedicines represent a class of advanced drug delivery systems that can potentially improve drug delivery into the eye. They have the potential to usher in a new era for eye therapeutics by replacing eyedrops as the primary mode of treatment for front of eye diseases and reducing reliance on eye injections for back of eye diseases. In this Ph.D. thesis, we reviewed the landscape for promising drug delivery systems in various stages of development for the treatment of eye inflammation. We then explored the use of liposomes as a drug delivery system for corticosteroids to treat eye inflammation, the most common key factor underlying ocular disease. Anterior uveitis and proliferative vitreoretinopathy (PVR) animal models, representing front and back of eye inflammation, respectively, were chosen to test our hypothesis that a single dose of liposomal steroids is effective and can provide sustained anti-inflammatory action for eye inflammatory diseases. Our promising preclinical results culminated in a first in man, Phase I/II clinical trial that demonstrated the safety and effectiveness of a single dose of liposomal steroid, injected under the conjunctiva as part of the surgical procedure, replacing eyedrops as anti-inflammatory treatment after cataract surgery. In conclusion, we demonstrated the attractiveness of a single dose of a liposomal drug delivery system in delivering steroid for the effective treatment of both front and back of eye diseases.

Purpose The purpose of this study was to assess whether the tractional elements of pathologic myopia (PM; e.g. myopic traction maculopathy [MTM], posterior staphyloma [PS], and aberrant posterior vitreous detachment [PVD]) are associated with myopic macular degeneration (MMD) independent of age and axial length, among highly myopic (HM) eyes. Methods One hundred twenty-nine individuals with 239 HM eyes from the Myopic and Pathologic Eyes in Singapore (MyoPES) cohort underwent ocular biometry, fundus photography, swept-source optical coherence tomography, and ocular B-scan ultrasound. Images were analyzed for PVD grade, and presence of MTM, PS, and MMD. The χ² test was done to determine the difference in prevalence of MMD between eyes with and without PVD, PS, and MTM. Multivariate probit regression analyses were performed to ascertain the relationship between the potential predictors (PVD, PS, and MTM) and outcome variable (MMD), after accounting for possible confounders (e.g. age and axial length). Marginal effects were reported. Results Controlling for potential confounders, eyes with MTM have a 29.92 percentage point higher likelihood of having MMD (P = 0.003), and eyes with PS have a 25.72 percentage point higher likelihood of having MMD (P = 0.002). The likelihood of MMD increases by 10.61 percentage points per 1 mm increase in axial length (P < 0.001). Subanalysis revealed that eyes with incomplete PVD have a 22.54 percentage point higher likelihood of having MMD than eyes with early PVD (P = 0.04). Conclusions Our study demonstrated an association between tractional (MTM, PS, and persistently incomplete PVD) and degenerative elements of PM independent of age and axial length. These data provide further insights into the pathogenesis of MMD.

Summary Background By 2050, almost 5 billion people globally are projected to have myopia, of whom 20% are likely to have high myopia with clinically significant risk of sight-threatening complications such as myopic macular degeneration. These are diagnoses that typically require specialist assessment or measurement with multiple unconnected pieces of equipment. Artificial intelligence (AI) approaches might be effective for risk stratification and to identify individuals at highest risk of visual loss. However, unresolved challenges for AI medical studies remain, including paucity of transparency, auditability, and traceability. Methods In this retrospective multicohort study, we developed and tested retinal photograph-based deep learning algorithms for detection of myopic macular degeneration and high myopia, using a total of 226 686 retinal images. First we trained and internally validated the algorithms on datasets from Singapore, and then externally tested them on datasets from China, Taiwan, India, Russia, and the UK. We also compared the performance of the deep learning algorithms against six human experts in the grading of a randomly selected dataset of 400 images from the external datasets. As proof of concept, we used a blockchain-based AI platform to demonstrate the real-world application of secure data transfer, model transfer, and model testing across three sites in Singapore and China. Findings The deep learning algorithms showed robust diagnostic performance with areas under the receiver operating characteristic curves [AUC] of 0·969 (95% CI 0·959–0·977) or higher for myopic macular degeneration and 0·913 (0·906–0·920) or higher for high myopia across the external testing datasets with available data. In the randomly selected dataset, the deep learning algorithms outperformed all six expert graders in detection of each condition (AUC of 0·978 [0·957–0·994] for myopic macular degeneration and 0·973 [0·941–0·995] for high myopia). We also successfully used blockchain technology for data transfer, model transfer, and model testing between sites and across two countries. Interpretation Deep learning algorithms can be effective tools for risk stratification and screening of myopic macular degeneration and high myopia among the large global population with myopia. The blockchain platform developed here could potentially serve as a trusted platform for performance testing of future AI models in medicine. Funding None.

Artificial intelligence (AI) has been billed as a key component of the Fourth Industrial Revolution. Currently, we are witnessing the growing shift of AI from theoretical ideations to practical applications in healthcare.1 2 Ophthalmology has emerged as one of the focal points of AI research.3–5 Current AI platforms are highly successful in screening for diabetic retinopathy, age-related macular degeneration and glaucoma.6–11 Other fields including cataract screening are similarly producing promising results.12 13 The WHO has identified that least 1 billion suffer from vision impairment that is preventable or treatable—of which myopia is a significant factor. With its growing prevalence in East Asia and many parts of the world, the ‘myopia pandemic’ is estimated to affect 50% (4.7 billion) of the world’s population by 2050, with 10% (1 billion) having high myopia (≤−5.00 D).14–16 This could lead to a staggering number of myopic individuals at risk of developing blinding conditions including myopic macular degeneration (MMD) and macular neovascularisation (MNV).17 However, AI research efforts in the field of refractive errors,18 particularly myopia19 are still relatively under-developed (table 1). View this table: Table 1 Summary of current Artificial Intelligence research in myopia The global attention towards myopia has led to a renewed focus on prediction, prevention, prognostication, early control as well as diagnostic accuracy.20 Early identification of high-risk individuals and unhindered access to appropriate healthcare will be critical in stemming the myopic tide. This has led to greater emphasis to develop dedicated AI models to address these unmet needs, especially for different phenotypes of myopia—childhood and adult myopia (high and pathological myopia). Relevant considerations include age, population size of each segment and measurable dataset, resource allocation, potential social burden, …

Background/aimsTo explore if retinal findings are associated with COVID-19 infection.MethodsIn this prospective cross-sectional study, we recruited participants positive for COVID-19 by nasopharyngeal swab, with no medical history. Subjects underwent retinal imaging with an automated imaging device (3D OCT-1 Maestro, Topcon, Tokyo, Japan) to obtain colour fundus photographs (CFP) and optical coherence tomographic (OCT) scans of the macula. Data on personal biodata, medical history and vital signs were collected from electronic medical records.Results108 patients were recruited. Mean age was 36.0±5.4 years. 41 (38.0%) had symptoms of acute respiratory infection (ARI) at presentation. Of 216 eyes, 25 (11.6%) had retinal signs—eight (3.7%) with microhaemorrhages, six (2.8%) with retinal vascular tortuosity and two (0.93%) with cotton wool spots (CWS). 11 eyes (5.1%) had hyper-reflective plaques in the ganglion cell-inner plexiform layer layer on OCT, of which two also had retinal signs visible on CFP (CWS and microhaemorrhage, respectively). There was no significant difference in the prevalence of retinal signs in symptomatic versus asymptomatic patients (12 (15.0%) vs 13 (9.6%), p=0.227). Patients with retinal signs were significantly more likely to have transiently elevated blood pressure than those without (p=0.03).ConclusionOne in nine had retinal microvascular signs on ocular imaging. These signs were observed even in asymptomatic patients with normal vital signs. These retinal microvascular signs may be related to underlying cardiovascular and thrombotic alternations associated with COVID-19 infection.

Background: To evaluate the distribution of the transforming growth factor-beta induced (TGFBI) corneal dystrophies in a multi-ethnic population in Singapore, and to present the different phenotypes with the same genotype. Methods: This study included 32 patients. Slit lamp biomicroscopy was performed for each patient to determine the disease phenotype. Genomic DNA was extracted from the blood samples and the 17 exons of the TGFBI gene were amplified by PCR and sequenced bi-directionally for genotype analysis. Results: Regarding phenotypes, the study patients comprised 11 (34.4%, 8 with R555W and 3 with R124H mutation) patients with granular corneal dystrophy type 1 (GCD1), 6 (18.8%, 5 with R124H and 1 with R124C mutation) patients with GCD2, 13 (40.6%, 7 with R124C, 2 with H626R, 2 with L550P, 1 with A620D and 1 with H572R) patients with lattice corneal dystrophy (LCD) and 2 (6.3%, 1 with R124L and 1 with R124C) patients with Reis&ndash, B&uuml, ckler corneal dystrophy. Regarding genotype, R124H mutation was associated with GCD2 (5 cases, 62.5%) and GCD1 (3 cases, 37.5%). R124C mutation was associated with LCD (7 cases, 87.5%) and GCD2 (1 case, 12.5%). All the 8 cases (100%) of R555W mutation were associated with GCD1. Conclusions: Although the association between genotype and phenotype was good in most cases (65.7%, 21 of 32 patients), genotype/phenotype discrepancy was observed in a significant number.

Background: The risk of pathologic myopia (PM) increases with worsening myopia and may be related to retinal microvasculature alterations. To evaluate this, we analyzed the macular microvasculature of myopes with swept source-optical coherence tomographic angiography (SS-OCTA) in adolescent and young adult Singaporeans.Methods: This is a prevalent case-control study including 93 young Chinese from the Strabismus, Amblyopia and Refractive error in Singaporean children (STARS, N = 45) study and the Singapore Cohort Study of Risk Factors for Myopia (SCORM, N = 48) studies. Macular vessel density (VD) measurements were obtained from 3 × 3 mm SS-OCTA scans and independently assessed using ImageJ. These measurements were compared between individuals with non-high myopia [non-HM, N = 40; SE >-5.0 diopter (D)] and HM (SE ≤-5.0D, N = 53).Results: The mean macular VD was 40.9 ± 0.6% and 38.2 ± 0.5% in the non-HM and HM, groups, respectively (p = 0.01 adjusted for age and gender). Mean FAZ area in the superficial layer was 0.22 ± 0.02 mm2 in the HM group, which was smaller compared to non-HM group (0.32 ± 0.03 mm2, p = 0.04). Mean deep FAZ area was similar between the two groups (0.45 ± 0.03 mm2 and 0.48 ± 0.04 mm2 in the HM and non-HM groups, respectively, p = 0.70).Conclusions: VD was lower and superficial FAZ area was smaller, in adolescents and young adults with HM compared to non-HM. These findings require validation in prospective studies to assess their impact on the subsequent development of PM.

PurposeTo quantify retinal and choriocapillaris (CC) microvasculature in highly myopic (HM) eyes with myopic macular degeneration (MMD) using swept-source optical coherence tomography angiography (SS-OCTA).Methods162 HM eyes (spherical equivalent ≤ −6.0 dioptres or axial length (AL) ≥26.5 mm) from 98 participants were enrolled, including 60 eyes (37.0%) with tessellated fundus, 54 eyes (33.3%) with peripapillary diffuse chorioretinal atrophy (PDCA), 27 eyes (16.7%) with macular diffuse chorioretinal atrophy (MDCA) and 21 eyes (13.0%) with patchy or macular atrophy. PLEX Elite 9000 SS-OCTA was performed to obtain perfusion densities (PD) of the superficial and deep retinal capillary plexus, and CC signal voids (number, area and density).ResultsRetinal PD decreased with increasing severity of MMD. Multivariable analysis showed that after adjustment of age and other factors, retinal PD decreased significantly in eyes with longer AL (β≤−0.51, pConclusionWe demonstrate significant OCTA alterations in the retina and CC in HM eyes with varying severities of MMD. In eyes with early-stage PDCA, lower retinal PD and more extensive CC signal voids are predominantly associated with increasing AL. In contrast, in eyes with MDCA or worse, MMD itself was associated with sparser retinal and CC circulation.

PURPOSE To investigate the prevalence and risk factors of posterior staphyloma using wide-field optical coherence tomography (WF-OCT) in adults with high myopia in Singapore. DESIGN Population-based cross-sectional study. METHODS Adults with spherical equivalent (SE) ≤ -5D in either eye at the first visit of Singapore Epidemiology of Eye Diseases study and Singapore Prospective Study Program study were recruited. Posterior staphyloma was diagnosed using WF-OCT (PLEX® Elite9000, Carl Zeiss Meditec). Myopic macular degeneration (MMD), myopic traction maculopathy (MTM) and vision-related quality of life (VRQoL) were assessed using fundus photographs, DRI-Triton OCT (Topcon) and the Impact of Vision Impairment (IVI) questionnaire, respectively. Factors associated with posterior staphyloma were identified with multilevel, multivariable logistic regression. Impact of posterior staphyloma on MMD, MTM and visual function was analysed with multilevel, multivariable logistic regression and linear mixed model, respectively. RESULTS Among the 225 eyes [mean SE = -6.5 ± 2.2 D, mean axial length (AL) = 26.2 ± 1.5 mm] of 117 participants (mean age = 60.3 ± 7.1 years), posterior staphyloma was detected in 47 (20.9%) eyes of 38 (32.5%) participants. Older age [odds ratio (OR), 1.18; 95% confidence interval (CI), 1.10-1.26], more myopic SE (0.63; 0.51-0.77) and increased AL (2.51; 1.69-3.73) were associated with higher prevalence of posterior staphyloma (all p

BACKGROUND: To describe the design, implementation, and evaluation of a nurse-led intravitreal injection (NL-IVT) programme in a Singapore tertiary eye hospital. METHODS: Patients requiring anti-vascular endothelial growth factor (VEGF) IVT were recruited. Implementation and evaluation were done in the Singapore National Eye Centre, a tertiary centre. To assess safety, nurse injectors recorded details of procedures performed and complications for an 8-month period from February 2019. To evaluate patient experience, we used a modified patient questionnaire and recorded both patients’ waiting time and IVT procedure duration. A retrospective audit of IVTs before and after the introduction of NL-IVT was performed from January 2017 to September 2019. Cost difference between NL-IVT and standard doctor-led (DL) IVT was evaluated. RESULTS: A total of 8599 NL-IVTs were performed. No cases of severe complication were detected in the follow-up. A total of 135 patients who received NL-IVT and DL-IVT were surveyed. General satisfaction, interpersonal manner, financial aspect, time spent with injector, and staff competence were higher in NL-IVTs than in DL-IVTs (p

Myopia is an emerging public health issue with potentially significant economic and social impact, especially in East Asia. However, many uncertainties about myopia and its clinical management remain. The International Myopia Summit workgroup was convened by the Singapore Eye Research Institute, the WHO Regional Office for the Western Pacific and the International Agency for the Prevention of Blindness in 2019. The aim of this workgroup was to summarise available evidence, identify gaps or unmet needs and provide consensus on future directions for clinical research in myopia. In this review, among the many ‘controversies in myopia’ discussed, we highlight three main areas of consensus. First, development of interventions for the prevention of axial elongation and pathologic myopia is needed, which may require a multifaceted approach targeting the Bruch’s membrane, choroid and/or sclera. Second, clinical myopia management requires co-operation between optometrists and ophthalmologists to provide patients with holistic care and a tailored approach that balances risks and benefits of treatment by using optical and pharmacological interventions. Third, current diagnostic technologies to detect myopic complications may be improved through collaboration between clinicians, researchers and industry. There is an unmet need to develop new imaging modalities for both structural and functional analyses and to establish normative databases for myopic eyes. In conclusion, the workgroup’s call to action advocated for a paradigm shift towards a collaborative approach in the holistic clinical management of myopia.

PurposeTo investigate the predictive factors for myopic macular degeneration (MMD) and progression in adults with myopia.MethodsWe examined 828 Malay and Indian adults (1579 myopic eyes) with myopia (spherical equivalent (SE) ≤–0.5 dioptres) at baseline who participated in both baseline and 12-year follow-up visits of the Singapore Malay Eye Study and the Singapore Indian Eye Study. Eye examinations, including subjective refraction and axial length (AL) measurements, were performed. MMD was graded from fundus photographs following the Meta-Analysis for Pathologic Myopia classification. The predictive factors for MMD development and progression were assessed in adults without and with MMD at baseline, respectively as risk ratios (RR) using multivariable modified Poisson regression models. The receiver operating characteristic curve was used to visualise the performance of the predictive models for the development of MMD, with performance quantified by the area under the curve (AUC).ResultsThe 12-year cumulative MMD incidence was 10.3% (95% CI 8.9% to 12.0%) among 1504 myopic eyes without MMD at baseline. Tessellated fundus was a major predictor of MMD (RR=2.50, pConclusionsIn adults with myopia without MMD, tessellated fundus, age, SE and AL had good predictive value for incident MMD. In adults with MMD, 1 in 10 eyes experienced progression over the same period. Older age, more severe myopia and longer AL were independent risk factors for progression.

To examine the progression pattern of disc and retinal lesions in highly myopic Chinese adolescents over a 10-year period in Singapore.This longitudinal study included Chinese participants who showed high myopia (spherical equivalent [SE] worse than or equal to -5 diopters [D]), no history of refractive surgery, and available fundus photographs at both 2006 (baseline) and 2016 (10-year follow-up) visits. Forty-four adolescents (aged 12-16 years at baseline) who were re-examined later at follow-up were included. Cycloplegic refraction, biometry, and fundus photography were performed at both visits. A trained grader classified myopic macular degeneration (MMD) based on the Meta-pathologic myopia classification and disc lesions from fundus photographs. Choroidal thickness (CT) measurements were performed at 10-year follow-up using swept-source optical coherence tomography. The ocular parameters and lesions were compared between baseline and follow-up.There was a significant worsening of high myopia at follow-up to -7.5±1.8 D (mean SE±SD) in 2016 versus -6.2±1.3 D in 2006; (P0.001). The 10-year changes included increased degree of tessellation (26 eyes, 29.5%), development of new tessellated fundus (19 eyes, 21.6%), disc tilt (7 eyes, 8.0%), and expansion of peripapillary atrophy size (33 eyes, 37.5%). Eyes with early-onset tessellation (present at baseline, 48 eyes) showed significantly thinner CT (P0.05), compared with eyes with late-onset tessellation (incident at 10-year follow-up, 19 eyes). No cases of MMD were recorded at baseline or 10-year follow-up.Although there was no incident MMD, the retinal and disc lesions worsened over the follow-up period. Early-onset fundus tessellation was associated with thinner CT.

Ocular anterior segment inflammation is a medical problem that is seen in cases of cataract surgery and non-infectious anterior uveitis. Inadequately treated anterior segment inflammation can lead to sight-threatening conditions such as corneal oedema, glaucoma and cystoid macular oedema. The mainstay of treatment for anterior segment inflammation is topical steroid eye-drops. However, several drawbacks limit the critical value of this treatment, including low bioavailability, poor patient compliance, relatively difficult administration manner and risk of blurring of vision and ocular irritation. A drug delivery system (DDS) that can provide increased bioavailability and sustained delivery while being specifically targeted towards inflamed ocular tissue can potentially replace daily eye-drops as the gold standard for management of anterior segment inflammation. The various DDS for anti-inflammatory drugs for the treatment of anterior segment inflammation are listed and summarised in this review, with a focus on commercially available products and those in clinical trials. Dextenza, INVELTYS, Dexycu and Bromsite are examples of DDS that have enjoyed success in clinical trials leading to FDA approval. Nanoparticles and ocular iontophoresis form the next wave of DDS that have the potential to replace topical steroids eye-drops as the treatment of choice for anterior segment inflammation. With the current relentless pace of ophthalmic drug delivery research, the pursuit of a new standard of treatment that eliminates the problems of low bioavailability and patient compliance may soon be realised.