Pathologic Myopia From Macular Detachment

September 14, 2005
Leonid Skorin, Jr, DO

A sudden and severe loss of central vision in her left eye sent a 51-year-old woman for medical consultation. She was very nearsighted (211.00 diopters) in both eyes. Corrected visual acuity in her unaffected right eye was 20/20; the best corrected visual acuity in her left eye was 20/400.

A sudden and severe loss of central vision in her left eye sent a 51-year-old woman for medical consultation. She was very nearsighted (211.00 diopters) in both eyes. Corrected visual acuity in her unaffected right eye was 20/20; the best corrected visual acuity in her left eye was 20/400.

Funduscopy of the left eye showed marked thinning of the retinal pigment epithelium and choroid, which afforded easy visibility of the larger choroidal vessels and the underlying white sclera. The macular area also showed a faintly gray semitranslucent plaque with a hyperpigmented border; this was a new vessel membrane (choroidal neovascularization). A hemorrhagic macular detachment was demonstrated just superior and adjacent to this membrane (A).

Fluorescein angiography confirmed the leaking membrane. A retina specialist thought that laser photocoagulation of the lesion would not be beneficial. Therefore, no therapy was initiated and follow-up appointments were scheduled. Three months later, the hemorrhage had completely resolved and a residual scar remained (B). Unfortunately, the patient's vision did not recover.

Myopia is the most common ocular abnormality, and degenerative myopia is one of the leading causes of blindness worldwide.1 Pathologic, or high, myopia is characterized by an increased axis length of the globe and a refractive error of at least 26.00 diopters.2 The patient with pathologic myopia complains of poor distance vision and floaters at an early age. By middle age, disturbances of central vision-including metamorphopsia and central vision loss-may occur. Retinal changes may consist of retinal pigment epithelial thinning, focal atrophy, breaks in Bruch membrane (lacquer cracks) from continued stretching of the globe, and choroidal neovascularization. Choroidal neovascularization occurs in 5% to 10% of eyes with pathologic myopia; it is the second most common cause of visual impairment.3 Hemorrhages are often secondary to the choroidal neovascularization.

Laser photocoagulation is considered only when the choroidal neovascular membrane is located outside the foveal avascular zon+H66e. Even with successful laser treatment and closure of the new vessels, atrophic subretinal scarring may result-and often progressively enlarges-causing permanent visual deterioration.1

REFERENCES:1. Cardillo J, Mercado HQ, Mieller W. Myopia. In: Mercado HQ, Alfaro DV, Liggett PE, et al, eds. Macular Surgery. Philadelphia: Lippincott Williams & Wilkins; 2000:357-362.
2. Skorin L. Pathologic myopia. In: Onofrey BE, Skorin L, Holdeman NR, eds. Ocular Therapeutics Handbook: A Clinical Manual. Philadelphia: Lippincott-Raven; 1998:450-453.
3. Campos R. La tache de Fuchs. In: Problemes Actuels d'Ophthalmologic. Basel: Karger; 1957:363-364.

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