Ophthal. Physiol. Opt.

2005 25: 381–391

Review Article

Myopia and associated pathological

complications
Seang-Mei Saw1,2,3, Gus Gazzard2,4, Edwin Chan Shih-Yen5 and
Wei-Han Chua2,3
1
Department of Community, Occupational and Family Medicine, National University of Singapore,
16 Medical Drive, Singapore 117597, 2Singapore Eye Research Institute, 3Singapore National Eye
Centre, Singapore, Singapore, 4Department of Wound Healing, The Institute of Ophthalmology,
London, UK, and 5NMRC Clinical Trials & Epidemiology Research Unit, Ministry of Health,
Singapore, Singapore

Abstract
Besides the direct economic and social burden of myopia, associated ocular complications may lead
to substantial visual loss. In several population and clinic-based cohorts, case–control and cross-
sectional studies, higher risks of posterior subcapsular cataract, cortical and nuclear cataract in
myopic patients were reported. Patients with high myopia (spherical equivalent at least –6.0 D) are
more susceptible to ocular abnormalities. The prevalent risks of glaucoma were higher in myopic
adults, and risks of chorioretinal abnormalities such as retinal detachment, chorioretinal atrophy and
lacquer cracks increased with severity of myopia and greater axial length. Myopic adults were more
likely to have tilted, rotated, and larger discs as well as other optic disc abnormalities. Often, these
studies support possible associations between myopia and specific ocular complications, but we
cannot infer causality because of limitations in study methodology. The detection and treatment of
possible pathological ocular complications is essential in the management of high myopia. The ocular
risks associated with myopia should not be underestimated and there is a public health need to
prevent the onset or progression of myopia.

Keywords: cataract, complications, glaucoma, myopia, pathological myopia, retinal tears

Myopia has reached epidemic proportions and is
already a large public health problem in certain parts
of the world, including East Asia (Grosvenor, 2003).
The rates of high myopia, and possibly pathological
myopia, appear to be rising in Asia and other parts of
the world. Cross-sectional prevalence surveys across the
United States (National Health and Nutrition Exam-
ination Survey, Baltimore Eye Survey, Beaver Dam Eye
Study, and the Framingham Offspring Eye Study)
suggest that there are higher myopia prevalence rates
Received: 25 October 2004
Revised form: 4 February 2005
Accepted: 21 February 2005
Correspondence and reprint requests to: A/Prof. Seang-Mei Saw.
Tel.: (65) 6 874 4989; Fax: (65) 6 779 1489.
E-mail address: cofsawsm@nus.edu.sg
with more recent birth cohorts (Sperduto et al., 1983;
Wang et al., 1994; The Framingham Offspring Eye
Study Group, 1996; Katz et al., 1997). The evidence for
this phenomenon from repeated prevalence surveys,
however, needs to be further substantiated because of
differences in methodology (Lin et al., 1988,1999). The
apparent worldwide rise in the prevalence of myopia has
a large public health impact because of the associated
concomitant increase in potentially blinding ocular
conditions.
Common definitions of high myopia or myopia with
increased risks of ocular morbidity, include spherical
equivalent (SphE) of at least –6.0 D, SphE at least –
8.0 D, or SphE at least –10.0 D. Ocular pathology is
usually due to excessive elongation of the eyeball and
associated with pathological changes in the fundus
(Goldschmidt, 1988; Tokoro, 1988). The terms Ômalig-
nant myopiaÕ, Ôdegenerative myopiaÕ and Ôpathological

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382 Ophthal. Physiol. Opt. 2005 25: No. 5
Table 1. Table of acronyms
SphE Spherical equivalent
D Diopters
AR Autorefraction
SR Subjective refraction
PSC Posterior subcapsular
RR Relative risk
OR Odds ratio
CI Confidence interval
AREDS Age-Related Eye Disease Study
CDR Cup–disc ratio
POAG Primary open-angle glaucoma
AL Axial length
VFD Visual field defect
OHTS Ocular Hypertension Treatment Study
IOP Intraocular pressure
AMD Age-related macular degeneration
myopiaÕ have also variously been used to describe
myopia accompanied by degenerative changes in the
sclera, choroid, retinal pigment epithelium and associ-
ated compromises in visual function (Duke-Elder,
1970; Daubs, 1982). Tokoro defined pathological
myopia as myopia caused by pathological axial elon-
gation and showed that the prevalence increased from
0.5% in junior high school Japanese students to a peak
of approximately 3% in 29-year-old adults (Tokoro,
1988).
We aim in this review to summarize the best
evidence of myopia-associated ocular pathologies,
including cataract, glaucoma, chorioretinal abnormal-
ities, optic disc abnormalities and age-related macu-
lar degeneration. Acronyms are summarized in
Table 1.
Myopia and cataract
Cataract is the leading cause of blindness worldwide
(Resnikoff et al., 2004). Data from studies of cataract
as a possible complication of myopia include popula-
tion-based cohort studies conducted in the United
States (Beaver Dam Eye Study), Australia (Blue
Mountains Eye Study) and Barbados (Barbados Eye
Study) (Lim et al., 1999; Wong et al., 2001; Leske
et al., 2002). Population-based cross-sectional studies
(both in Australia) and clinic-based case–control stud-
ies (UK) are also presented in Table 2 (Brown and Hill,
1987; McCarty et al., 1999; Younan et al., 2002).
Refraction measurements were determined by either
autorefraction (AR) or subjective refraction (SR) or
both. Cataract was confirmed by lens photography. In
the Blue Mountains Eye Study (n ¼ 2334; follow-
up ¼ 5 years) of adults 49 years and older, the multi-
variate adjusted odds ratio (OR) of incident PSC was
4.4 (95% CI 1.7, 11.5) for moderate myopia (SphE at
least –3.5 D) compared with emmetropia, and 3.3 (95%
CI 1.5, 7.4) for nuclear cataract in adults with high
myopia (SphE at least –6.0 D) (Younan et al., 2002).
There were also associations with prevalent posterior
subcapsular (PSC), cortical and nuclear cataract.
Refraction-related increasing odds were found between
PSC cataract and myopia: low myopia (OR 2.1; 95%
CI 1.4, 3.5), moderate myopia (OR 3.1; 95% CI 1.6,
5.7) and high myopia (OR 5.5; 95% CI 2.8, 10.9). PSC,
cortical, and late nuclear cataract were associated with
high myopia (Lim et al., 1999). The multivariate
adjusted OR of incident nuclear cataract in myopic
adults (SphE at least –0.5 D) in the Barbados Eye
Study of adults aged 40–84 years (n ¼ 2609; follow-
up ¼ 4 years) was 2.8 (95% CI 2.0, 4.0) (PSC and
cortical cataract results were not reported) (Leske
et al., 2002). Myopia was not associated with incident
cataract in the Beaver Dam Eye Study of adults 43–
84 years (n ¼ 4470; follow-up ¼ 5 years), but only with
prevalent nuclear cataract [OR 1.74 (95% CI 1.28,
2.37)] (Wong et al., 2001).
From prevalence estimates, we cannot infer that
cataract is a complication of myopia because it is also
possible that adults with cataract may have higher
risks of myopia. Associations with PSC, cortical and
nuclear prevalent cataract were found in the Visual
Impairment Project in Australia (n ¼ 5147) of adults
40 years and older (McCarty et al., 1999). However,
no relationship between myopia and cataract was
found in a case-control study in the UK (n ¼ 220) of
adults 40 years and above (Brown and Hill, 1987).
In the Age-Related Eye Disease Study (AREDS) of
4477 adults aged 60–80 years, participants with
myopia had ORs of 0.72 for mild nuclear opacity
and 0.85 for mild cortical opacity compared with
hyperopes (Age-related Eye Disease Study Research
Group, 2001).
From the cross-sectional studies, we cannot exclude
the possibility that myopic shifts may have occurred as
a consequence of cataract (notably nuclear) develop-
ment. The cataract–myopia relationship may be in the
opposite direction and the progression of opacity in the
lens nucleus may initiate the development of myopia.
However, there is a large body of evidence from
population and clinic-based studies that cataract (PSC,
nuclear and occasionally, cortical cataract) may be
associated with high and low myopia in European-
derived and Caribbean African populations (Brown and
Hill, 1987; Lim et al., 1999; McCarty et al., 1999; Wong
et al., 2001; Leske et al., 2002; Younan et al., 2002).
The mechanism by which myopia may lead to lens
changes is unknown. However, myopia has been linked
to damage of rod outer segments and increased
production of potentially cataractogenic lipid peroxida-
tion by-products (Zigler et al., 1983).
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 Table 2. Summary of published data on cataract as a complication of myopia (for abbreviations see Table 1)
Author (Year) Methodology and
(Country) Ethnicity Study design Study population (n) definitions Results

Brown and Hill Case-control Cases (cataract patients) SR Lens photography The crude OR of myopia (not defined) ¼ 1.06 (95% CI 0.6, 1.9)
(1987) (UK) study and controls (patients (cataract) (computed from table 7 using unmatched analysis)
White without cataract) aged
40 years or older, matched
by age at a London
ophthalmic clinic. High

ª 2005 The College of Optometrists

myopia (SphE at least –12 D)
excluded (n ¼ 220)
Lim et al. Population-based Blue Mountains Eye Study AR and SR Lens OR of prevalent cataract for high myopes (SphE at least –6.0 D),
(1999) cross-sectional 49 years and older (7308 eyes) photography (cataract) adjusted for age, sex, smoking, hypertension, diabetes, steroid
(Australia) study use and sun-related skin damage, were:
White 4.9 (95% CI 2.1, 11.4) for PSC
2.9 (95% CI 1.4, 6.0) for cortical cataract
1.4 (95% CI 0.8, 2.4) for nuclear cataract
McCarty et al. Population-based Visual Impairment Project AR Lens photography OR of prevalent cataract for myopia (SphE at least –1.0 D) were:
(1999) cross-sectional 40 years and older (n ¼ 5147) (cataract) 3.59 (95% CI 2.50, 5.15) for PSC, adjusted for age, rural,
(Australia) study diuretics, vitamin E, vitamin A, ultraviolet light
White 1.76 (95% CI 1.30, 2.40) for cortical cataract, adjusted for age,
gender, iris, arthritis, diabetes, gout, beta-blockers, ultraviolet
light, glaucoma
2.73 (95% CI 1.90, 3.92) for nuclear cataract, adjusted for age,
gender, diabetes, smoking and education
Wong et al. Population-based Beaver Dam Eye Study AR (baseline) Lens OR of prevalent cataract for myopia (SphE at least –1.0 D),
(2001) (US) cohort study 43–84 years (n ¼ 4470) photography (prevalent adjusted for age, gender, diabetes, smoking, and education, were:
White (FU ¼ 5 years) cataract at baseline and 1.23 (95% CI 0.75, 2.03) for PSC
incident cataract at 5 years) 0.86 (95% CI 0.64, 1.16) for cortical cataract
1.74 (95% CI 1.28, 2.37) for nuclear cataract
Myopia was not associated with incident cataract
Younan et al. Population-based Blue Mountains Eye Study AR and SR (baseline) OR of incident cataract were:
(2002) cohort study 49 years and older Lens photography 4.4 (95% CI 1.7, 11.5) of moderate
(Australia) (n ¼ 2334) (FU ¼ 5 years) (cataract at 5 years) myopia (SphE at least –3.5 D) for PSC, adjusted for age, sex,
White education, obesity, hypertension, nuclear cataract
0.5 (95% CI 0.2, 2.0) of high myopia (SphE at least –6.0 D) for
cortical cataract, adjusted for age, sex, education, alcohol,
ultraviolet light, diabetes, obesity, stroke, nuclear cataract
3.3 (95% CI 1.5, 7.4) of high myopia (SphE at least –6.0 D) for
nuclear cataract, adjusted for age, sex, smoking, education,
iris, inhaled steroids
Leske et al. Population-based Barbados Eye Study AR (baseline) Lens RR of incident cataract for myopia (SphE at least –0.5 D),
(2002) cohort study 40–84 years (n ¼ 2609) photography adjusted for age, gender, body mass index, iris color, diabetes,
(Barbados) (FU ¼ 4 years) (cataract at 4 years) IOP, and IOP treatment was 2.8 (95% CI 2.0, 4.0) for nuclear
Myopic pathological complications: Seang-Mei Saw et al.

Caribbean cataract (PSC and cortical cataract not reported)

Africans
383
384 Ophthal. Physiol. Opt. 2005 25: No. 5
Myopia and glaucoma
Myopic eyes are structurally different from emmetropic
eyes: myopic eyes have longer axial lengths and vitreous
chamber depths (Scott and Grosvenor, 1993). Eyes with
increased axial length appear to have higher cup–disc
ratios (CDRs), increased optic nerve fibre layer defects
and possibly greater deformability of the lamina crib-
rosa, leading to higher susceptibility to glaucomatous
optic disc changes (Fong et al., 1990). The glaucoma–
myopia association has been described in case–control
and cross-sectional studies in Europe, Asia, Australia
and the USA, but its effect on incident glaucoma has not
yet been evaluated in prospective cohort studies
(Table 3) (Daubs and Crick, 1981; Ponte et al., 1994;
Mitchell et al., 1999; Grodum et al., 2001; Yoshida
et al., 2001; Wong et al., 2003). As the temporal
relationship between glaucoma and myopia is not well
delineated, a cause-effect relationship between myopia
and glaucoma cannot be established. The definitions of
primary open-angle glaucoma (POAG) differed and
refraction measures were assessed by autorefraction
(AR) or subjective refraction (SR). All studies found
associations of glaucoma with myopia in patients aged
40 years and older [Casteldaccia Eye Study (n ¼ 264):
OR ¼ 5.56; Beaver Dam Eye Study (n ¼ 4670):
OR ¼ 1.6] (Ponte et al., 1994; Wong et al., 2003).
Several studies showed that glaucoma risks increased
with more severe myopia. The OR of glaucoma for
moderate myopia was 3.3 in the Blue Mountains Eye
study of 3654 adults while glaucoma rates increased with
increasing myopia in logistic regression models (regres-
sion coefficient –0.373, p < 0.001) in 32 918 Swedes
(Mitchell et al., 1999; Grodum et al., 2001). In Japan
(n ¼ 64 394), there were positive associations between
the strength of myopic refraction and the prevalence of
OAG for specific age-gender groups (p < 0.001 in men
and p < 0.001 in women) (Yoshida et al., 2001). For
example, in women aged 65–74 years, 5.4% of those
with moderate-to-high myopia had OAG in contrast to
2.0% of those with hyperopia. The relative risk (RR) of
glaucoma for high myopia (SphE at least –5.0 D) in the
UK (n ¼ 953) was 3.1 (Daubs and Crick, 1981). The
Casteldaccia Eye Study, Blue Mountains Eye Study,
Beaver Dam Eye Study and Swedish studies were
population-based, while eye clinic patients were exam-
ined in studies conducted in Japan and the UK.
It appears that glaucoma may be more common in
patients with longer ALs, though changes in risk
estimates with varying ALs have not been addressed in
published studies. There is no well-defined value of AL
that is associated with higher risks of glaucoma. The
severity of glaucomatous VFDs and optic disc abnor-
malities were shown to be greater in myopic adults
(Quigley et al., 1994; Chihara et al., 1997; Jonas and
Dichtl, 1997). In the Ocular Hypertension Treatment
Study (OHTS) of the effect of topical ocular hypotensive
medication in preventing the onset of POAG, myopia (a
baseline risk factor) was not associated with incident
POAG (Gordon et al., 2002).
The effects of myopia on IOP, as well as the incidence
and severity of glaucomatous VFDs and optic disc
changes, have also been evaluated (Greve and Furuno,
1980; Quinn et al., 1995; Chihara et al., 1997; Ko et al.,
2002; Wong et al., 2003). In a cross-sectional survey of
children in a Philadelphia hospital (n ¼ 321), the mean
IOP of myopic eyes (17.8 mm Hg) was higher compared
with non-myopic eyes (17.1 mm Hg) (p < 0.01) (Quinn
et al., 1995). This relationship remained after control-
ling for age, family history of myopia and amblyopia.
The increase in VFD was greater (1.04 mean change in
rank of VFD) in adults with high myopia (SphE at least
–4.0 D) compared with emmetropes (0.53) in 122 POAG
Japanese patients (Chihara et al., 1997). In another
study of 993 white adults with ocular hypertension,
refractive error did not predict incident glaucomatous
VFD (Quigley et al., 1994). The optic discs were larger
(p < 0.0001), shape more elongated (p < 0.0005) and
cup depth significantly shallower (p < 0.0001) in 44
highly myopic (SphE at least –5.0 D) white POAG
patients compared with 571 POAG patients with low to
moderate myopia or hyperopia (Jonas and Dichtl,
1997).
Myopia and chorioretinal abnormalities
Increased axial elongation in myopes may lead to
mechanical stretching and thinning of the choroid and
retinal pigment epithelium with concomitant vascular
and degenerative changes (Pierro et al., 1992). A myriad
of chorioretinal abnormalities associated with myopia
have been evaluated in one case–control and five cross-
sectional clinic-based studies. These abnormalities
include retinal breaks, chorioretinal atrophy, Fuch’s
spot, lacquer cracks, pigmentary degeneration, lattice
degeneration, posterior staphyloma and white without
pressure (Table 4) (Hyams and Neumann, 1969; Curtin
and Karlin, 1970; Karlin and Curtin, 1976; Celorio and
Pruett, 1991; Pierro et al., 1992; The Eye Disease Case–
Control Study Group, 1993; Yura, 1998). Data of
associations of prevalent retinal abnormalities with
varying AL (n ¼ 3), presence of myopia (n ¼ 2), as well
as the severity of myopia (n ¼ 1) are available.
However, these findings are derived from clinic-based
populations and have yet to be confirmed in population-
based cohort studies of incident retinal abnormalities.
Ideally, population-based cohort studies describing the
association between myopia and incident chorioretinal
abnormalities should be conducted to provide valuable
data.
ª 2005 The College of Optometrists
 Table 3. Summary of published data on glaucoma as a complication of myopia (for abbreviations see Table 1)
Author (Year) Methodology and
(Country) Ethnicity Study design Study population (n) definitions Results

Daubs and Crick Case–control General ophthalmology SR OR of OAG was 3.1 (95% CI 1.6, 5.8) for high myopia
(1981) (UK) White study patients, King’s College OAG defined as (SphE at least –5.0 D), 1.3 (95% CI 1.0, 1.8) for low myopia

ª 2005 The College of Optometrists

Hospital, London (n ¼ 953) eyes with open angles (SphE > –0.25 D to –5.0 D) compared with hyperopia
and characteristic VFD (SphE at least + 0.25 D), adjusted for age, IOP, sex,
family history, season, blood pressure, astigmatism,
urinalysis and health
Ponte et al. (1994) Population-based Casteldaccia Eye Study Cases: IOP ‡ 24 mm Hg, OR of prevalent glaucoma for myopia (SphE at least –1.5 D)
(Italy) White case–control study 40 years and older (n ¼ 264) or history of glaucoma, was 5.56 (95% CI 1.85, 16.67), adjusted for diabetes,
or visual fields suggestive hypertension, steroid use and iris texture
of glaucoma. Controls:
subjects with IOP £ 20 mmHg,
cup-disc ratios 0–0.2
and pink discs
Mitchell et al. Population-based Blue Mountains Eye Study AR and SR OR of prevalent OAG was 3.3 (95% CI 1.7, 6.4) for moderate
(1999) (Australia) cross-sectional study 49 years and older (n ¼ 3654) OAG defined as to high myopia (SphE at least –3.0 D) and 2.3 (95% CI 1.3, 4.1)
White cup-disc ratio ‡0.7 or for patients with low myopia (SphE < –3.0 D and ‡)1.0 D),
cup-disc asymmetry ‡0.3 adjusted for sex, family history, diabetes, hypertension,
migraine, steroid use and pseudoexfoliation
Grodum et al. Population-based Residents of Malmo born AR Prevalence of newly detected OAG increased with increasing
(2001) (Sweden) cross-sectional study between 1918 and 1932 OAG defined as repeatable myopia (SphE at least –1 D) (p < 0.01). [0.6% in hypermetropia
White (n ¼ 32 918) VFD on two consecutive (‡+1.0 D); 0.9% in emmetropia (SphE > –1 D to < + 1 D) and
tests on different days 1.5% (SphE £)1 D) in moderate to high myopia], adjusted for
age, gender and IOP
Yoshida et al. Cross-sectional study Optometry clinic patients, AR Prevalence of OAG higher for moderate to high myopes
(2001) (Japan) Yokohama, 6–98 years OAG defined as (SphE at least –3 D) compared with hyperopes in males
Japanese (n ¼ 64 394) glaucomatous VFD associated (p < 0.001) and females (p < 0.001)
with abnormal optic disc
and/or disc margin
Wong et al. Population-based Beaver Dam Eye Study AR and SR The age and gender adjusted ORs of prevalent POAG for
(2003) (USA) cross-sectional study 43–86 years (n ¼ 4670) POAG defined myopia (SphE at least –1.0 D) was 1.6 (95% CI 1.1, 2.3)
White as VFD compatible with
glaucoma, IOP ‡22 mm Hg,
cup–disc ratio 0.8 or more,
history of glaucoma treatment
Myopic pathological complications: Seang-Mei Saw et al.
385
 386

Table 4. Summary of published data on chorioretinal abnormalities as complications of myopia (for abbreviations see Table 1)
Author (Year) Methodology and
(Country) Ethnicity Study design Study population (n) definitions Results

Hyams and Cross-sectional Asymptomatic eye clinic patients Slit-lamp biomicroscopy 13% of high myopes (SphE at least –6.0 D),
Neumann (1969) study with myopia at least –1.0 D, aged 10.7% of moderate myopes (SphE –3.25 to –6.0 D)
(Israel) White 10–65 years (332 eyes) and 10.5% of low myopes (SphE –1.0 to –3.0 D)
had retinal breaks
Curtin and Karlin Cross-sectional Eye clinic patients with myopia A scan (AL) Percentage of chorioretinal atrophy was 0%
(1970) Karlin and study (1437 eyes) Patients with hyperopia Binocular indirect if AL < 24.5 mm and 23% if AL ‡24.5 mm
Curtin (1976) or emmetropia (n ¼ 100) ophthalmoscopy (BIO) + direct Percentage with Fuch’s spot was 0% if < 26.5 mm and
(USA) White ophthalmoscopy (Curtin and Karlin) 5.2% if ‡26.5 mm
Ophthal. Physiol. Opt. 2005 25: No. 5

or scleral indentation (Karlin and Percentage with lacquer cracks was

Curtin) 0% if < 26.5 mm and 4.3% if ‡26.5 mm
Percentage white without pressure
increased from 0% at 20–21 mm to 54% at 33 mm
Percentage lattice degeneration
increased with AL (p < 0.01)
Celorio et al. Cross-sectional Records of patients with high myopia A scan (AL) Percentage of lattice degeneration decreased
(1990) (USA) study (SphE at least –6.0 D) reviewed BIO with scleral depression with AL (40.9% for AL 26–26.9 mm and 7.0%
White (n ¼ 218; 436 eyes) Slit-lamp biomicroscopy for 32 mm or greater)
Pierro et al. Cross-sectional Patients in an ophthalmology clinic A scan (AL) Percentage of eyes with one of more retinal lesions
(1992) (USA) study with AL ‡24 mm (n ¼ 513) Slit-lamp (white with or without pressure; lattice degeneration;
White biomicroscopy with pavingstone degeneration; posterior vitreous
scleral depression detachment) increases with AL
The Eye Disease Case–control Cases of idiopathic rhegmatogenous AR/SR The OR of retinal detachment for myopes
Case–Control Study study retinal detachments and age-sex- Confirmed retinal (SphE at least –1 D) was 7.8 (95% CI 5.0, 12.3),
Group (1993) race-clinic matched controls (free of detachment from adjusted for age, sex, race and clinic
(USA) White retinal disease) from five eye surgical records
centres, high myopia (SphE at
least –8 D) excluded (n ¼ 1391)
Yura (1998) (Japan) Cross-sectional Clinic patients with high myopia AR and SR Percentages of posterior staphyloma, but not
Japanese study (AL’s 26–31.99 mm) A scan (AL) lattice degeneration increased with AL
(n ¼ 542; 970 eyes) BIO with scleral depression

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 Myopic pathological complications: Seang-Mei Saw et al. 387

the neural rim area by 0.029 mm2 (95% CI 0.025, 0.034), and
The prevalence of lattice degeneration, which is a risk

(95% CI 0.03%, 0.8%), and zone beta by 1.3% (95% CI 0.57,

The disc area increased by 0.033 mm2 (95% CI 0.027, 0.038),

the prevalence of parapapillary atrophy [zone alpha by 0.4%

ratio (p < 0.001), larger discs (p < 0.01), higher likelihood of
decreased (p < 0.01), the ratio of vertical to horizontal disc
factor for developing retinal breaks, increased with AL

With increasing myopia, the temporal slope of the disc cup

Patients with myopia (SphE at least -5.0 D) had a longer

disc–foveola distance (p < 0.001), larger long:short axis
in 2 studies by Curtin and Karlin (1,437 eyes of all

(SphE at least –1.0 D), but in eyes without tilted discs

In eyes with tilted discs (77 eyes), 66.2% were myopic
atrophy to vertical disc diameter increased (p < 0.01)
diameter (p < 0.01) and ratio of width of peripapillary
ages), and Pierro (513 patients) in white patients aged
10 years and above in the USA (Curtin and Karlin,

(7,089 eyes), 11.3% were myopic (p < 0.001)

1970; Karlin and Curtin, 1976; Pierro et al., 1992). No

1.9%)] for each D increase towards myopia

association was, however, found in a study of 542

tilted (p < 0.001), rotated disc (p < 0.01)

Japanese patients of all ages (Yura, 1998). We noted
that in a clinic-based study of 218 white patients of all
ages in the USA, the prevalence was actually lower in
patients with extreme AL (>32 mm) (Celorio and
Pruett, 1991). The prevalence of retinal breaks in Israeli
eye clinic patients aged 10–65 years (332 eyes) was 13%
with high myopia (SphE at least –6.0 D), but only
10.5% in patients with low myopia (SphE –1.0 to –
3.0 D) (Hyams and Neumann, 1969). This difference,
though, may not be clinically significant and patients

Results
who present at the clinic may be more likely to have dual

Table 5. Summary of published data on optic disc abnormalities as complications of myopia (for abbreviations see Table 1)
pathology (retinal breaks and high myopia). The
prevalence of posterior vitreous detachment, which is

Tilted disc defined as inferior or

SR, Stereoscopic photographs.
Cycloplegic streak retinoscopy,
involved in the development of many retinal breaks, was

nasal tilting of the optic disc

12.5% in a case series of patients with high myopia and

stereoscopic photographs

Stereoscopic photographs
60.7% in patients with AL of more than 30.0 mm

AR + SR, Stereoscopic
(Morita et al., 1995). Other vitreous changes observed in
Methodology and

myopic eyes include posterior vitreous lacunae and

extensive vitreous liquefaction (Stirpe and Heimann,

photographs
definitions

1996). The multivariate adjusted OR of idiopathic

rhegmatogenous retinal detachment in myopic adults
was 7.8 (95% CI 5.0, 12.3) in white patients aged 21–
80 years in the Eye disease Case–Control Study (The Eye
Seoul National University Hospital

Disease Case–Control Study Group, 1993). However,

the prevalence of retinal tears, holes and detachment did
Male Koreans, eye department,

astigmatism (cylinder <1.5 D)

Rotterdam study 55 years and

49 years or older in the Blue

not increase with longer AL (Pierro et al., 1992).
with IOP < 21 mm Hg and

Healthy Japanese at Kyoto

Mountains, West Sydney

The evidence from the available literature assessing
Study population (n)

chorioretinal abnormalities is not strong because there

University (n ¼ 210)
(n ¼ 61; 109 eyes)

are no large studies that delineate in a prospective

older (n ¼ 5114)

fashion the association between refractive error or AL.

(n ¼ 3583)
Possible myopic pathology includes Fuch’s spot, lacquer
cracks, lattice degeneration, and retinal breaks. Fuch’s
spots and lacquer cracks are entities often defined
clinically as occurring in the setting of pathological
myopia. Choroidal neovascularization and macular
cross-sectional study

cross-sectional study

holes in myopic adults have been well characterized

Population-based

Population-based

clinically in case studies, but not cross-sectional, case–

Cross-sectional

Cross-sectional
Study design

control or cohort studies (Avila et al., 1984; Stirpe and

Michels, 1990).
study

study

Myopia and optic disc abnormalities

Chihara and Chihara
(Country) Ethnicity

Hyung et al. (1992)

Netherlands) White

The risks of optic disc abnormalities in adults with

(Korea) Koreans E

(2002) (Australia)
Vongphanit et al.
Ramrattan et al.

myopia and high myopia were evaluated in East Asian

(1994) (Japan)
Author (Year)

university-based and white population-based studies

(1999) (The
Japanese

(Rotterdam Study and Blue Mountains Eye Study)

White

(Table 5) (Hyung et al., 1992; Chihara and Chihara,

1994; Ramrattan et al., 1999; Vongphanit et al., 2002).

ª 2005 The College of Optometrists

388 Ophthal. Physiol. Opt. 2005 25: No. 5
In all four studies described in Table 5, disc abnormal-
ities were assessed using stereoscopic photographs. In
the Japanese study (n ¼ 210) by Chihara and Chihara
(1994), myopic patients had significantly higher rates of
larger, tilted, rotated discs, larger disc areas, longer disc-
foveola distances, and larger long:short axis ratios. In
the Blue Mountains Eye Study (n ¼ 3,583; aged
49 years or older), subjects with tilted discs were more
likely to be myopic (66.2%), compared with subjects
with no tilted discs (p < 0.001) (Vongphanit et al.,
2002). Increasing severity of myopia was associated with
an increase in prevalent optic disc abnormalities in the
clinic-based Korean (n ¼ 61) and the population-based
Rotterdam study (n ¼ 5,114) (Hyung et al., 1992;
Ramrattan et al., 1999). In a study by Fulk and col-
leagues of 224 subjects aged 8–25 years, myopic refract-
ive error was associated with large optic nerve crescents
(Fulk et al., 1992). While myopic optic disc abnormal-
ities may appear innocuous, they are important clinically
because they can be difficult to evaluate. The detection of
both glaucoma and progression of glaucomatous optic
neuropathy may be delayed in these patients. There is
also evidence that larger discs may be more susceptible
to the effects of intra-ocular pressure and intra-ocular
pressure-related stress (Bellezza et al., 2000).
Myopia and age-related macular degeneration
Three recent population-based studies: the Blue Moun-
tains Eye Study (3654 white subjects aged 49 years or
older; cross-sectional study), Beaver Dam Eye Study
(3684 white subjects aged 43–86 years; cohort study),
and National Health and Nutrition Examination Survey
(less than 10 000 white subjects aged 45 year or older;
cross-sectional study) have evaluated the association of
myopia and AMD (Goldberg et al., 1988; Wang et al.,
1998; Wong et al., 2002). No significant associations of
myopia with prevalent or incident AMD were found.
Pathological myopia as a cause of visual impairment
Pathological myopia is a potentially blinding disease:
cataract and glaucoma are leading causes of blindness
and visual impairment. Myopic degeneration is also a
significant cause of visual impairment worldwide. In the
Rotterdam study of 6775 subjects aged 55 years and
older, myopic degeneration was the predominant cause
of impaired vision (accounting for 23.0% in adults
younger than 75 years) (Klaver et al., 1998). There were
12 cases of impaired vision younger than 75 years and
eight cases of myopic degeneration due to impaired
vision in adults younger than 75 years and only 11 cases
of myopic degeneration in total. Thus, the total number
of adults affected is small. A study of 1000 inhabitants
aged 60–80 years in Copenhagen revealed that myopic
macular degeneration was one of the most common
causes of bilateral blindness (accounting for 10%) (Buch
et al., 2001). Again, the total number of cases of myopic
macular degeneration due to blindness was only two and
thus the overall impact of myopic degeneration may not
be large. On the other hand, in a survey of adults
50 years or older in Taiwan, myopic macular degener-
ation was the second most common cause of visual
impairment (contributing 25.0% of cases) (Liu et al.,
2001). Similarly, a survey by Iwano and colleagues in
Japan of 2263 adults aged 40–79 years showed that the
OR of visual impairment for myopic adults was 2.9
(95% CI 1.4, 6.0) (Iwano et al., 2004). In Asian
countries, myopia may be a leading cause of visual
impairment because of the higher overall rates of
myopia and high myopia. Further large surveys of the
contribution of myopia to visual impairment in different
populations should be conducted. Myopia may also be
under corrected if the lens prescription is not updated or
myopia remains undiagnosed. Under corrected myopia
is also one of the leading causes of visual impairment
and is easily correctable.
Conclusion
The impact of myopia, an apparently benign ocular
disease, may be larger than it seems. A greater under-
standing of the potentially blinding risks of myopia by
ophthalmologists and optometrists may facilitate the
screening and management of myopia-related ocular
complications. Severe myopia may be associated with
increased risks of ocular complications and the preven-
tion of the onset of myopia or the progression of low
myopia to high myopia is of utmost importance.
Cohort studies have shown that cataract (PSC, nuclear
and occasionally, cortical cataract) is a complication of
myopia (Lim et al., 1999; Wong et al., 2001; Leske et al.,
2002). A survey of the findings of the literature in
European-derived and Asian populations suggests that
myopic adults have an increased prevalent risk of
glaucoma, although no cohort studies depicting the
temporal relationship between myopia at baseline and
incident glaucoma risks are available (Daubs and Crick,
1981; Ponte et al., 1994; Mitchell et al., 1999; Grodum
et al., 2001; Yoshida et al., 2001; Wong et al., 2003). In
clinic-based studies, chorioretinal abnormalities such as
lacquer cracks and lattice degeneration have been asso-
ciated with refractive error or AL (Hyams and Neumann,
1969; Curtin and Karlin, 1970; Karlin and Curtin, 1976;
Celorio and Pruett, 1991; Pierro et al., 1992; The Eye
Disease Case–Control Study Group, 1993; Yura, 1998).
Our synthesis of the literature in European-derived and
Asian populations also shows higher prevalence of optic
disc abnormalities such as tilted disc in the myopic
population (Hyung et al., 1992; Chihara and Chihara,
ª 2005 The College of Optometrists
 Myopic pathological complications: Seang-Mei Saw et al.
1994; Ramrattan et al., 1999; Vongphanit et al., 2002).
However, data from well-designed cohort studies showed
no increased risks of AMD with myopia (Wang et al.,
1998; Wong et al., 2002). Several studies show that the
risks of cataract, glaucoma, and chorioretinal abnorm-
alies increase with increasing myopic refraction or axial
length (Curtin and Karlin, 1970; Karlin and Curtin,
1976; Pierro et al., 1992; Lim et al., 1999; Mitchell et al.,
1999; Grodum et al., 2001).
Risk estimates (multivariate RRs) from several large
population-based cohort studies demonstrated strong
evidence of associations of myopia and ocular patho-
logy such as cataract (Lim et al., 1999; Wong et al.,
2001; Leske et al., 2002). The inferences from other
studies in the literature are limited because of the cross-
sectional nature of the studies, small sample sizes, or
unadjusted risk estimates. Ascertainment bias may be
present in clinic-based studies because patients who
attend the clinic for their myopia may be more likely to
have other ocular pathologies. This may lead to spuri-
ous associations between glaucoma and myopia, or
cataract and myopia. This bias is worse for diseases that
are largely asymptomatic. The current best available
evidence cannot conclusively support the hypothesis
that myopia causes ocular pathology. Only suggestions
of possible associations may be inferred. There is also
the issue of publication bias. Even if a hypothesis does
not have a strong biological plausibility, it may be
possible that positive results are reported. Conversely,
negative associations from other possibly well-designed
studies are often not published.
Several important questions remain unanswered: Are
both low myopia and high myopia associated with
higher risks of ocular complications? Do the risks of
specific ocular pathology increase with more severe
myopia or greater AL? Is the pattern of pathological
myopia different in Asian and non-Asian countries? Will
the rates of pathological myopia rise over the next few
decades?
The following issues have not been well addressed
thus far. The hereditary susceptibility to pathological
myopia in Asian and non-Asian countries may differ. In
addition, the public health burden of pathological
myopia may be unique in Asian countries. Thus,
comparisons of pathological complications in Asian
and non-Asian countries would be of utmost clinical
importance. The appropriate cutoff limit for high and
malignant myopia is unclear; correlations of different
levels of severity of myopia and specific pathologies need
to be further studied before clinical guidelines can be
developed. Perhaps even low degrees of myopia may be
associated with significant risks of ocular complications.
The evaluation of contributions to visual loss and
optimal treatment of associated chorioretinal lesions
will assist in the assessment of ocular morbidity contri-
ª 2005 The College of Optometrists
389
buted by each anomaly. Other myopia-associated
pathologies such as myopia-associated cataract may
also contribute significantly to visual impairment.
In conclusion, patients with myopia, especially high
myopia, may have higher risks of cataract, glaucoma,
and chorioretinal abnormalities such as retinal detach-
ment and optic disc abnormalities. Pathological myopia
is one of the most common causes of visual impairment
and blindness. The early detection and management of
degenerative eye diseases is of utmost importance in the
care of myopic adults. Additional data from different
ethnic populations are needed to describe the effects of
varying severity of refractive error and AL on the
incident risks of specific ocular pathological complica-
tions. Currently, there are many challenges for myopia
research. The accurate prediction of the burden of
ocular pathology in myopic children and adults has
important clinical implications and should be a priority
research area for eye care professionals.
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