EDITORIAL

Standardization of High Myopia Optic Nerve Head

Abnormalities May Help Diagnose Glaucoma in
High Myopia
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Timothy P.H. Lin, MBChB*, Nishant V. Radke, MD†,

Poemen P. Chan, FRCSEd (Ophth), FCOphth (HK)*‡§∥,
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 02/07/2024

Clement C. Tham, FCOphth (HK), FRCOphth*‡§∥,

and Dennis S.C. Lam, MD¶#

(Asia Pac J Ophthalmol (Phila) 2023;12:425–426)

yopia is a major worldwide public health issue, particularly in the Asia-Pacific region.1–3 The prevalence
M of myopia has exponentially increased in the past decades and is now recognized by the World Health
Organization as a leading cause of visual impairment.4 High myopia is of grave concern because it is associated
with sight-threatening ocular comorbidities like myopic maculopathy, glaucoma, and retinal detachment.
High myopia is generally defined as a refractive error of ≤ −6 D (spherical equivalent) in the context of axial
length ≥ 26.5 mm.5,6 Holden et al5 estimated that 163 million people (2.7% of the world population) had high
myopia in the year 2000 and was predicted to rise to 938 million (9.8% of the world population) by 2050. The
development of myopia involves the progressive and excessive axial elongation of the globe. Pathologic myopia
may occur in highly myopic eyes with characteristic degenerative changes in the posterior segment, which can
result in irreversible vision loss. The cardinal features of pathologic myopia include posterior staphyloma7 and
myopic maculopathy. To date, literature provides detailed definitions of the characteristic macular lesions in
myopic maculopathy based on the findings of fundus examination and optical coherence tomography (OCT).8,9
Currently, pathologic alterations of the optic nerve and optic neuropathy related to high myopia are recognized
yet ill-elaborated in myopia research. Earlier studies have reported a 28.5% of prevalence of glaucomatous optic
neuropathy (GON) in high myopia. Indeed, high myopia eyes were 5.9 times more likely to develop GON than
emmetropic eyes.10 Nevertheless, structural abnormalities in the optic nerve head (ONH) with corresponding
perimetric defects have also been demonstrated in pathologic myopia with myopic maculopathy.11 Therefore, it
would be of interest to clinicians to understand the underlying structural abnormalities of the optic nerve in high
myopia and to differentiate the optic neuropathy that arises due to high myopia from glaucoma.
In this issue of the Asia-Pacific Journal of Ophthalmology, Jiang et al11 conducted a cross-sectional study by
secondary analysis of data from a longitudinal cohort which included 1389 eyes of 857 highly myopic patients
without pathologic myopic maculopathy to determine the prevalence and characteristics of ONH structural
abnormalities on OCT and their relationship with visual field (VF) defects.
The authors reviewed swept-source OCT scans and classified 12 distinct ONH abnormalities based on 3 cate-
gories: optic disc morphology, papillary/peripapillary tissue defects, and papillary/peripapillary schisis. Their inves-
tigation revealed over 90% of eyes showed at least 1 ONH abnormality, and nearly 35% had 3 or more, with up to
27.3% demonstrating correspondence in the locations of VF defects were present. The most prevalent VF defect in
nonpathologic high myopia was the enlargement of a blind spot on perimetry. This is the first study to demonstrate
the presence of ONH structural abnormalities with a functional relationship to VF defects in nonpathologic high

Submitted July 1, 2023; accepted July 31, 2023.

From the *Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China; †The C-MER
(Shenzhen), Dennis Lam Eye Hospital, Shenzhen, Guangdong Province, China; ‡Hong Kong Eye Hospital, Hong Kong, China; §Lam Kin
Chung Jet King-Shing Ho Glaucoma Treatment and Research Centre, Department of Ophthalmology and Visual Sciences, The Chinese
University of Hong Kong, Hong Kong, China; ∥Department of Ophthalmology and Visual Sciences, The Prince of Wales Hospital, Hong
Kong, China; ¶The International Eye Research Institute of The Chinese University of Hong Kong (Shenzhen), Shenzhen, Guangdong
Province, China; and #The C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong, China.
The authors have no funding or conflicts of interest to declare.
Address correspondence and reprint requests to: Dennis S.C. Lam, The International Eye Research Institute of The Chinese University of
Hong Kong (Shenzhen), Shenzhen 518172, Guangdong Province, China. E-mail: dennislam@hkcmer.com
Copyright © 2023 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy
of Ophthalmology. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No
Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work
cannot be changed in any way or used commercially without permission from the journal.
ISSN: 2162-0989
DOI: 10.1097/APO.0000000000000635

r 2023 Asia-Pacific Academy of Ophthalmology. https://journals.lww.com/apjoo | 425

 Editorial Asia-Pacific Journal of Ophthalmology
myopia. VF defects in high myopia may be secondary to the
development of GON, myopic maculopathy in pathologic my-
opia, or high myopia optic neuropathy (HMON). Xie et al12
recently demonstrated that up to 63% of eyes with pathologic
myopia had VF defects. Nevertheless, it is known that myopic
maculopathy present in pathologic myopia could result in VF
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defects that mimic glaucomatous VF loss and confound the
clinical interpretation of the perimetry in highly myopic eyes.13
Based on the recently reported classification system of VF ab-
normalities in nonpathologic high myopia by Lin et al,6 the
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current study has further demonstrated the structural-functional
relationship between ONH abnormalities and VF defects in
nonpathologic high myopia. This provides crucial evidence to
aid clinicians in establishing a diagnosis of HMON, which has
been challenging to discern from GON and myopic maculop-
athy when VF defects arise in a highly myopic eye. Some in-
teresting findings emerge from this detailed phenotypic
characterization. First, certain ONH abnormalities such as
peripapillary hyperreflective ovoid mass-like structures
(PHOMS), visible retrobulbar subarachnoid space, and prel-
aminar schisis were more prevalent than previously recognized.
Second, some ONH abnormalities coexisted frequently. Eyes
with shallow optic cups often had PHOMS, while those with
optic disc drusen commonly showed PHOMS. Those with per-
ipapillary retinoschisis often also had prelaminar schisis. Third,
ONH abnormalities corresponded to different VF defect pat-
terns. Glaucoma-like defects occurred more often with deep
optic cups and pits, while high myopia defects correlated with
tissue defects and schisis. It would be of immense relevance to
ophthalmologists in the decades to come, given a global aging
and growing myopia population, among which GON and
HMON are likely to become prevalent sight-threatening eye
diseases.
In conclusion, there are rising interests in myopia
because of the growing myopic population and its related
ocular comorbidities. Zhang and colleagues have success-
fully demonstrated that characteristic ONH abnormalities
with corresponding VF defects were present in non-
pathologic high myopia due to HMON. These results argue
for the inclusion of ONH evaluations in classifications and
monitoring of high myopia. The novel and fundamental
knowledge of HMON and the classification of its structural
and functional abnormalities would propel and support fu-
ture clinical and epidemiologic research in this field. With
the rapid advancement of artificial intelligence,14–16 the
standardization in classification would be a crucial first step
in diagnosing and monitoring HMON in the era of digital
medicine.
426 | https://journals.lww.com/apjoo
 Volume 12, Number 5, September/October 2023
REFERENCES
1. Morgan IG, Jan CL. China turns to school reform to control the myopia
epidemic: a narrative review. Asia Pac J Ophthalmol (Phila). 2022;11:
27–35.
2. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012;379:
1739–1748.
3. Yusufu M, Bukhari J, Yu X, et al. Challenges in eye care in the Asia-
Pacific region. Asia Pac J Ophthalmol (Phila). 2021;10:423–429.
4. Resnikoff S, Pascolini D, Mariotti SP, et al. Global magnitude of visual
impairment caused by uncorrected refractive errors in 2004. Bull World
Health Organ. 2008;86:63–70.
5. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia
and high myopia and temporal trends from 2000 through 2050.
Ophthalmology. 2016;123:1036–1042.
6. Lin F, Chen S, Song Y, et al. Classification of visual field abnormalities in
highly myopic eyes without pathologic change. Ophthalmology. 2022;129:
803–812.
7. Ohno-Matsui K, Jonas JB. Posterior staphyloma in pathologic myopia.
Prog Retin Eye Res. 2019;70:99–109.
8. Ruiz-Medrano J, Montero JA, Flores-Moreno I, et al. Myopic
maculopathy: current status and proposal for a new classification and
grading system (ATN). Prog Retin Eye Res. 2019;69:80–115.
9. Ohno-Matsui K, Kawasaki R, Jonas JB, et al. International photographic
classification and grading system for myopic maculopathy. Am J
Ophthalmol. 2015;159:877–883.
10. Pan CW, Cheung CY, Aung T, et al. Differential associations of myopia
with major age-related eye diseases: the Singapore Indian Eye Study.
Ophthalmology. 2013;120:284–291.
11. Jiang J, Song Y, Kong K, et al. Optic nerve head abnormalities in non-
pathologic high myopia and the relationship with visual field. Asia Pac J
Ophthalmol (Phila). 2023;12:460–467.
12. Xie S, Kamoi K, Igarashi-Yokoi T, et al. Structural abnormalities in
the papillary and peripapillary areas and corresponding visual field
defects in eyes with pathologic myopia. Invest Ophthalmol Vis Sci.
2022;63:13.
13. Lanca C, Sun CH, Chong R, et al. Visual field defects and myopic
macular degeneration in Singapore adults with high myopia. Br J
Ophthalmol. 2022;106:1423–1428.
14. Ting DSW, Pasquale LR, Peng L, et al. Artificial intelligence and deep
learning in ophthalmology. Br J Ophthalmol. 2019;103:167–175.
15. Clark P, Oermann EK, Chen D, et al. Federated AI, current state, and
future potential. Asia Pac J Ophthalmol (Phila). 2023;12:310–314.
16. Yang D, Ran AR, Nguyen TX, et al. Deep learning in optical coherence
tomography angiography: current progress, challenges, and future
directions. Diagnostics (Basel). 2023;13:326.
r 2023 Asia-Pacific Academy of Ophthalmology.