Myopia-Related Macular Diseases: Treatment and Outcomes

Educational Objectives

The goal of this program is to improve the management of myopia-related macular diseases. After hearing and assimilating this program, the clinician will be better able to:

1. Develop management strategies for macular diseases associated with myopia.

Summary

Clinical presentation: may include metamorphopsia or decreased visual acuity (VA), but may be asymptomatic; fundus findings include atrophy in the macula, posterior staphyloma, and peripapillary region, and lacquer cracks; optical coherence tomography (OCT) is helpful for assessment of macular pathology because it is difficult to assess on examination alone

Myopic choroidal neovascularization (CNV): presentation may be subtle and require OCT or fluorescein angiography to confirm; CNV can grow through lacquer cracks; Förster-Fuchs retinal spot (elevation of the retinal pigment epithelium) is indicative of regressed CNV

Treatment options: photocoagulation — rarely used if CNV is in the macula; anti-vascular endothelial growth factor (VEGF) injections — predominant treatment used; RADIANCE trial (Wolf et al, 2014) found that ranibizumab injections were superior to photodynamic therapy (mean improvement in Early Treatment Diabetic Retinopathy Study [ETDRS] letter score of 10.6 vs 2.2 at 3 mo); treatment was effective with a mean of 3.5 injections based on disease activity in the first year; ≈63% of eyes did not need ranibizumab injections at 6 to 12 mo

Myopic traction maculopathy: 9% to 34% of eyes with severe myopia and posterior staphyloma have some degree of myopic traction maculopathy; includes foveoschisis, maculoschisis, retinoschisis, retinal and foveal detachments, outer lamellar hole, full-thickness hole, and hole with localized detachment; occurs secondary to preretinal and subretinal factors and forces; differential diagnosis for schisis includes X-linked retroschisis, S-cone syndrome, optic nerve pits, stellate nonhereditary idiopathic foveomacular retroschisis, peripapillary pachychoroid syndrome

Management: includes pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peelings, macular buckling, or combined vitrectomy and macular buckling; observation may be considered for mild cases; preoperative factors that determine outcomes include visual acuity, duration of symptoms, axial length, presence of a foveal detachment, staphyloma height, and preoperative choroidal thickening

PPV with ILM peeling: relieves tangential traction that causes macular schisis and foveal detachment; studies show that 79% of cases have improvement in the foveal thickness ≤3 mo; inner retinoschisis resolves most quickly; outer retinoschisis resolved in 82% of cases ≤3 mo; foveal detachment resolves in ≈90% of cases at 6 mo; external foveal retinoschisis resolves in most cases

Macular buckling: infrequently performed in the United States; studies found success rate of 93% with macular buckling and 73% to 83% with vitrectomy in patients with macular hole-related retinal detachment; Zhao et al (2022) found no difference in visual improvement and faster reattachment rate with combination of macular buckling and PPV compared with PPV alone

Myopic macular hole: management is similar to that of myopic maculoschisis; vitrectomy or tamponade (gas or silicone) may be considered, particularly for the eye with better vision; ILM peeling may be considered; ILM flap, amniotic membrane, or retinal patch grafting may be considered for large holes

Readings

Beaumont W, Couturier A, Gaudric A, et al. Myopic foveoschisis completely resolves within 12 months after vitrectomy. Ophthalmol Retina. 2022;6(12):1221-1230. doi:10.1016/j.oret.2022.06.003; Wolf S, Balciuniene VJ, Laganovska G, et al. RADIANCE: a randomized controlled study of ranibizumab in patients with choroidal neovascularization secondary to pathologic myopia. Ophthalmol. 2014;121(3):682-92.e2. doi:10.1016/j.ophtha.2013.10.023; Zhao X, Li Y, Ma W, et al. Macular buckling versus vitrectomy on macular hole associated macular detachment in eyes with high myopia: a randomised trial. Br J Ophthalmol. 2022;106(4):582-586. doi:10.1136/bjophthalmol-2020-317800.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. MacCumber is a consultant for Bausch & Lomb, Genentech, Novartis, and Regeneron. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. MacCumber was recorded at UIC 16th Annual Retina Symposium - Current and Emerging Treatment for Common Retinal Conditions, held March 17, 2023, in Chicago, IL, and presented by University of Illinois College of Medicine and the Illinois Eye and Ear Infirmary. For information on future CME activities from this presenter, please visit https://chicago.medicine.uic.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

OP611402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.