ABSTRACT Myopia is one of refraction errors type, which is the image of distant objects focuses in front of retina in the

unaccomodated eye. It is the common form of refraction errors. Myopia patient have a twofold to threefold increased risk of glaucoma, especially the primary open angle glaucoma, compared with those who are not myopia (emmetropia). This association is stronger for eyes with moderate to high myopia.Patient with high myopia (spherical equivalent at least -6.0 D) are more susceptible to ocular abnormalities. Some researches show that there is correlation between high myopia ad primary open angle glaucoma. Keywords : high myopia, primary open angle glaucoma,refraction error

INTRODUCTION Background High myopia (HM), also know as pathological myopia or progressive myopia, is highly prevalent and may lead to blindness. The prevalence of high myopia varies considerably in different ethnic groups and has been estimated to be around 10% in Asian populations.(1,2) Most of litteratures tell that high myopia have major risk to be glaucoma, especially primary open angle glaucoma (POAG).POAG is progressive, chronic optic neuropathy in adults where intraocular pressur (IOP) and other curently unknown factors contribute to damage and in which, in the absence of other indentifiable causes, there is a charateristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and their axons. Glaucoma affects approximately 2,2 million adults in United States, about 1,9% of people >40 years old. The POAG is the most common form of glaucoma and as many as half of those with POAG are unaware that they have the disease. (3) This two condition is commonly happen and both recently studies and epidemiology show that they have correlation. Therefore, I would like to review the correlation between them from the aspect of definition, epidemiology, clinical features and how to diagnosis. Method The creation of this paper is made possible with the aid of various sources such as textbook, medical website, and medical journal.

High Myopia or Pathological Myopia

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Definition Myopia (or shortsightedness, or nearsightedness) is a condition in which distant objects are not displayed sharply on the retina by the optical system of the eye, because the rays converge already before they hit the retina.(4) Myopia can divided into refractive myopia, the refractive power of the lens system is too high, and axial myopia which is the distance between the lens system and the retina is too large. Pathological myopia or high myopia is one of axial myopia type. It is a condition defined by refractive error in excess of -6.00D with an axial length greater than 26mm. In addition, the disease is characterized by degenerative and progressive changes involving a physical stretching of the sclera, choroid and retina. (4,5) Ethiology The cause of pathological myopia is unknown, but it occurs if the length of the eyeball is more than the average length of about 24 mm. Beside that, it believes that high myopia is associated with inherited.(4) Epidemiology The prevalence of myopia increases in school-age and young adult cohorts, reaching 20-25 percent in the mid to late teenage population and 25-35 percent in young adults in the United States and developed countries. It is reported to be higher in some areas of Asia.(6) Not all eyes that have myopia greater than -6D progress nor does every eye that has pathological myopia develop degenerative complications. In the United States, the disease affects 2% of the population, and is the seventh leading cause of blindness. Further, it has been reported that there is increased prevalence of the disease particularly in Asian populations.According to a recent study from Japan, pathological myopia was the third leading
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cause of bilateral vision loss and the leading cause of monocular vision loss in that population.
(7,8)

Risk Factor An important risk factor for the development of simple myopia is a family history of myopia. Studies have shown a 33-60 percent prevalence of myopia in children whose parents both have myopia. In children who have one parent with myopia, the prevalence was 23-40 percent. Doing a substantial amount of near work on a regular basis can increase the risk for myopia. Myopia is associated with greater time spent reading and doing near work, better reading test scores, more years of education, occupations that require a great deal of near work, and greater academic ability Steeper corneal curvature and a ratio of axial length to corneal radius that is greater than 3.00 may also be risk factors. In children, conditions that prevent normal ocular image formation (e.g., eyelid hemangiomas, neonatal eyelid closure, corneal opacity, retrolental fibroplasia associated with retinopathy of prematurity, and vitreous hemorrhage) often result in myopia. These relatively severe disruptions result in a high degree of myopia, which is usually pathological.(6) Clinical features The most common symptom associated with uncorrected myopia is blurred distance vision. The decreased of vision normally will stabillized on 20 years old. But not in high myopia or pathological myopia, it will continous decreased. Diagnosis

Myopia can diagnosed by use Snellen chart or pinhole.Pathological myopia can often be detected during routine eye examinations. The condition is diagnosed when eyeball elongation is greater than 26. Primary Open Angle Glaucoma Definition Primary open-angle glaucoma (POAG) is one of glaucoma classificcation which is a progressive optic neuropathy characterized by acquired loss of retinal ganglion cells and atrophy of the optic nerve.(9) Ethiology and Risk Factor The studies said that 60 to 70% of this disease have no identifiable cause. That is why it termed primary open-angle glaucoma. Both eyes usually are affected, but typically not equally. The only known causative risk factors for open-angle glaucoma are elevated intraocular pressure and insults to the eye, including trauma, uveitis.Associated risk factors, in addition to age, include black race, which increases the prevalence of glaucoma by a factor of four, and a positive first-degree family history, which increases the prevalence by a factor of seven. Because there is strnng familial tendency in POAG, and close relatives of affected individuals should undergo regular screening. Otherwise, there also the possible risk of glaucoma such as high myopia, diabetes, hypertention.(9)

Here are the major risk factor associated with POAG :(10,11)

Risk Factor

Prevalence of glaucoma (%)

Relative Risk of Glaucoma

Race Black White Asian Older age (odds ratio per decade increase) Black White Asian 1.6 2.1 1.6 4.2 2.1 1.4

Elevated Intraocular Pressure 1.0 <15 mmHg 2.0 16-18 mmHg 2.8 19-21 mmHg 12.8 22-29 mmHg 29.0 30-34 mmHg

Family history in first degree relative Myopia

2.9

1.6-3.3
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Risk Factor

Prevalence of glaucoma (%) 1.7

Relative Risk of Glaucoma

Thin central cornea Epidemiology

POAG is the most common form of glaucoma in blacks and whites. In the USA, about 0,4-0.7% of persons over age 40 and 2-3% of persons over age 70 are estimated to have primary open-angle glaucoma. The disease is four time more commmon and six times more likely to cause blindless in blacks.(12) Clinical Presentation The symptom of POAG is asymtomatic. After loss of more than 40 percent of the nerve fibers, patients may notice a gradual loss of peripheral vision, or tunnel vision.Open-angle glaucoma usually is an incidental finding during an adult eye evaluation performed for other indications.(9,12) The main clinical features of primary open-angle glaucoma are an open iridocorneal angle and cupping of the optic-nerve head (or optic disk), with corresponding loss of visual field. Elevated intraocular pressure is not part of the clinical definition because primary open-angle glaucoma can occur when intraocular pressure is normal (typically10 to 21 mm Hg). Nevertheless, elevated intraocular pressure is an important risk factor and is also considered to be a causative factor in glaucoma.(13)

Diagnosis

To diagnose POAG, some examination should be held in people who have major risk to be glaucoma. They have to check their visus with snellen, check visual field by using perimetry, optic nerve by using ophtalmoscopy and measure their IOP with tonometry. With ophtalmosccopy, it will show optic nerve atrophy, increased cup:disk ratio, thinning of the neurosensory rim. The other condition can be find is visual field defect which is caused by lesions o the optic nerve Tonometry will show an elevated intraocular pressure. Approximately 25% of patients with POAG have normal IOP when first examination, so repeated tonometry maybe necessary before the diagnosis can be established.(12,14) The Correlation Between High Myopia and Primary Open Angle Glaucoma High myopia eyes are structurally different from emmetropic eyes. High Myopia eyes have longer axial lengths and vitreous chamber depths. Eyes with increased axial length appear to have higher cupdiscratios (CDRs), increased optic nerve fibre layer defectsand possibly greater deformability of the lamina cribrosa,leading to higher susceptibility to glaucomatous optic disc changes .(15) There are several explanation for the close relation between high myopia and primary open angle glaucoma.First, with the same intraocular pressure (IOP), more tension is added on the sclera of myopic eyes than emmetropic eyes. Second, in myopic existence of glaucoma predispose fundus to damage and the last, IOP elevation often leads to extension of ocular axis.
(2)

At the end of the 20th century, new gene theories, colagene gave a better explanation on the HM-POAG relation. Myopic Collagen Gene Pathological observatoin of myopic chicken models revealed that in HM, the chondric lamina of sclera became thicker, the number of binuclear cells increased, and density of cells decreased.All these indicate that there is an increase of chondric cell
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proliferation and secretion.Electron microscopy revealed that in HM, sclera was mainly arranged as lamellar, colagen fiber bundle,the diameter of the fibers decreased; a greater dispersion for the range of fibers, as well as greater prevalenc eof fiber groups with uniform but extremely fine diameter adversely affected the development, organization, and maturation of the collage framework. All these lead to the ultramicroscopic change in pathologic myopia. Change of collagen fiber in POAG Observations of aqueous ouflowsystem showed that more collagenous fiber existed in the trabecular meshwork and in this region, the basement membrane also became thicker. Furthermore it is recognized atrophy if the optic nerve fibers in POAG originates from lamina cribosa, where collagenous fiber is one of the main extrainterstitial macromoolecules. Recently it was found that the number and density of type IV collagen protein increased in POAG. Investigations also demonstrated that under certain pressure, synthesis of collagen protein was associated with the corresponding genetic expression. Scientists generally agree that it is collagen fiber defects caused by IOP elevation that damage and thin lamina cribosa, and eventualy result in atrophy of the optical nerve fiber. To sum up, both HM and POAG are considered as diseases characterictic of collagen lesion.(2) Beside the theory and the characteristic of high myopia (pathological myopia), epidemiology studies shows that myopia 1.85 [95% CI, 1.033.31] for low myopia and 2.60 [95% CI, 1.56 4.35] for moderate to high myopia were associated with an increased risk of having POAG in Japan. Whereas, in Australia, glaucoma was present in 4.2% of eyes with low myopia and 4.4% of eyes with moderate-to-high myopia compared to 1.5% of eyes without myopia.( 3,16)

CONCLUSION High myopia also known as pathological myopia have major risk to be primary open angle glaucoma, despite age and family history. Both this diseases have relation based on the new theory, collagen gene theories. Despite that, many of epidemiological studies also shown that primary open angle glaucoma occurs in people who have high myopia.
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12. Riordan-Eva Paul. Glaucoma. In : Riordan-Eva Paul, Whitcher John,editors. Vaughan & Asburys General Ophtalmology.16th ed New York : McGraw-Hill ; 2004. p 212-21 13. Bahrami H. Causal inference in primary open angle glaucoma: specific discussion on intraocular pressure. Ophthalmic Epidemiol 2006;13:283-9. 14. Rhee Douglas. Primary Open Angle Glaucoma.2008. Available at http://www.merckmanuals.com/professional/sec09/ch103/ch103b.html. Acessed June 12, 2011 15. Saw Seang-Mei, Gazzard Gus, Chua Wei-Hen, Chan Edwin. Myopia and Associated Pathological Complications. Ophthal. Physiol. Opt.2005. p381-91 16. Suzuki Yasuyuki, Iwase Aiko,Araire Makoto,Yamamoto Tetsuya, et al.Risk Factors for Open-Angle Glaucoma in a Japanese Population. American Academy of Opthalmology.2006. p 1613

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