September 2023
Volume 64, Issue 12
Open Access
Retina  |   September 2023
The Clinical Role of the Choroidal Assessment in High Myopia: Characteristics and Association With Neovascular and Atrophic Complications
Author Affiliations & Notes
  • Alessandro Arrigo
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Emanuela Aragona
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Lorenzo Bianco
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Alessio Antropoli
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Andrea Saladino
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Francesco Bandello
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Maurizio Battaglia Parodi
    Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
  • Correspondence: Alessandro Arrigo, Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy; [email protected]
Investigative Ophthalmology & Visual Science September 2023, Vol.64, 16. doi:https://doi.org/10.1167/iovs.64.12.16
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      Alessandro Arrigo, Emanuela Aragona, Lorenzo Bianco, Alessio Antropoli, Andrea Saladino, Francesco Bandello, Maurizio Battaglia Parodi; The Clinical Role of the Choroidal Assessment in High Myopia: Characteristics and Association With Neovascular and Atrophic Complications. Invest. Ophthalmol. Vis. Sci. 2023;64(12):16. https://doi.org/10.1167/iovs.64.12.16.

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Abstract

Purpose: To investigate the clinical utility of choroidal quantitative assessment associated with the presence of macular neovascularization (MNV) or atrophy in high myopia.

Methods: The study was designed as a retrospective case series with two-year follow-up. We measured choroidal thickness (CT) and the presence and subtype of dome-shaped macula (DSM). In DSM eyes we also calculated the presence and type of choroidal deepening (CD). The eyes were categorized as Subgroup 1 (high myopia without complications), Subgroup 2 (high myopia complicated by MNV), and Subgroup 3 (high myopia complicated by macular or posterior pole atrophy). Main outcome measures were the detection of significant CT cutoffs associated with the three subgroups of eyes and the clinical impact of DSM and CD subtypes.

Results: Our cohort (190 eyes affected by high myopia) was categorized as Subgroup 1 (66 eyes), Subgroup 2 (72 eyes) and Subgroup 3 (52 eyes). Baseline CT values allowed to separate the subgroups with myopic-related complications (area under the curve = 0.85; P < 0.05). In Subgroup 1, vertical DSM was the most frequent (54%), with CD absence characterizing the 46% of cases. Round DSM was the most represented subtype in Subgroup 2 (49%), with 55% of sub-dome CD subtypes; in these cases, MNV resulted always localized in the fovea. Subgroup 3 equally shown horizontal or vertical DSM (53% and 47%, respectively), with 80% of cases showing peri-dome CD.

Conclusions: Choroidal quantitative assessment can categorize three high myopia subgroups. MNV subgroup is characterized by intermediate choroidal thinning and higher prevalence of round DSM with sub-dome CD.

Pathologic myopia is characterized by several patterns of degenerative changes occurring in those eyes with refractive error greater than −6D and axial length longer than 26 mm. The estimated prevalence of pathologic myopia is 0.9% to 3.1%, and it can be complicated by macular neovascularization (MNV), macular atrophy or vitreomacular disorders.1 MNV occurs in at least 5.2% to 11.3% of cases, recognizing partially defined risk factors, including longer axial length and possible genetic factors.1,2 Two important risk factors of complications were recognized in choroidal thinning and dome-shaped aspect.1,2 Choroidal thinning has been associated either with the risk of MNV onset and macular atrophy.3 Moreover, the occurrence of dome-shaped aspect of the retina has been associated with further risk of myopic-related complications.4 However, scant data are available in the literature regarding the identification of clinically relevant cutoffs suggestive of higher risk of MNV onset. In the present study we retrospectively analyzed a cohort of patients affected by high myopia to assess the clinical utility of choroidal quantitative assessment for the stratification of the risk of onset of MNV or atrophy. 
Material and Methods
We designed the study as a retrospective case series with two years of follow-up. We included myopic eyes characterized by highly negative refractive error (greater than −6D) and eye elongation (axial length >26.5 mm). The presence of radial, raster, and dense optical coherence tomography scans (Heidelberg HRA2+OCT Spectralis; Heidelberg Engineering, Heidelberg, Germany) represented a further mandatory criterion. In addition, we included only examinations performed in the time range between 10 AM and 4 PM to reduce the impact of possible choroidal thickness diurnal variations. Exclusion criteria were other ocular disorders interfering with the interpretation of the findings (vascular occlusive disorders, uveitis, glaucoma), high media opacity or other causes of poor imaging quality, ophthalmic surgery performed at least six months before the baseline visit and during the planned follow-up, history of any kind of vitreoretinal surgery, and uncontrolled systemic conditions potentially interfering with the results of the study. The study was conducted in accordance with the Helsinki declaration and was approved by the ethical committee of IRCCS San Raffaele Scientific Institute (protocol ID: MIRD2020). 
Bearing in mind the current ways to classify pathologic myopia, particularly the meta-analysis for pathologic myopia (META-PM) five categories classification5 and the recently proposed atrophic-tractional-neovascular (ATN) classification,6 we segregated our patients into three different subgroups by using a simplified categorization. In particular, we considered: high myopia with not clinically relevant signs of neovascular, atrophic or vitreoretinal complications (Subgroup 1), high myopia complicated by MNV (Subgroup 2) and high myopia complicated by macular or posterior pole atrophy, and possible coexistence of vitreoretinal disorders (Subgroup 3). This choice was done because the main goal of the present study was to identify cutoff values segregating those eyes complicated by MNV from pathologic myopia without neovascular complication. With respect to Subgroup 3, the mandatory criterion was no history or present clinical and instrumental evidence of MNV. 
We measured the mean choroidal thickness (CT) considering five single measures performed beneath the fovea, 750 µm and 1500 µm far from the fovea, in a horizontal fovea-centered OCT line, on its left and right sides, respectively. In addition, we considered the dome-shaped macular aspect (DSM), when present, as defined as the inward macular protrusion greater than 50 µm in the vertical or horizontal direction.7,8 We separately considered horizontal DSM, vertical DSM, or oval DSM.9 Moreover, we used the same method proposed by Zhao and colleagues9 to assess choroidal deepening (CD) and to distinguish sub-dome choroidal deepening (SDCD), peri-dome choroidal deepening (PDCD), and the absence of CD (Fig. 1). 
Figure 1.
 
The three patterns of choroidal changes in DSM. (A) A case of high myopia without DSM. To evaluate the presence of CD, choroidal thickness measure was performed at the top of the dome and the bottom of the dome. (B) A case of DSM with no CD, showing uniform choroidal thickness at the top (blue arrow) and the bottom (red arrows) of the dome. (C) A case of SDCD, where the choroid resulted thicker at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows). (D) A case of PDCD, where the choroid resulted thinner at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows).
Figure 1.
 
The three patterns of choroidal changes in DSM. (A) A case of high myopia without DSM. To evaluate the presence of CD, choroidal thickness measure was performed at the top of the dome and the bottom of the dome. (B) A case of DSM with no CD, showing uniform choroidal thickness at the top (blue arrow) and the bottom (red arrows) of the dome. (C) A case of SDCD, where the choroid resulted thicker at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows). (D) A case of PDCD, where the choroid resulted thinner at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows).
All patients underwent complete ocular examination including the measure of LogMAR best-corrected visual acuity (BCVA), anterior and posterior slit lamp examination, and applanation tonometry. The diagnosis of MNV was confirmed by fluorescein angiography. Structural OCT images were also used to detect retinal fluids in MNV subgroups, separately considering subretinal fluid, intraretinal fluid, and subretinal hyperreflective material. The measures were taken by two blinded graders (A.A., L.B.) who considered baseline, one-year, and two-year timepoints. Interclass correlation coefficient was calculated to check the agreement between the two graders. 
For the three subgroups we chose the following timepoints. For Subgroup 1 three structural OCT (baseline, one-year, and two-year follow-ups) without signs of neovascular, atrophic, or vitreoretinal complications; for Subgroup 2 baseline visit was considered as the last OCT examination before the onset of MNV, then one-year and two-year follow-up images; for Subgroup 3 baseline visit corresponded to the first examination present in our database; then we also included one-year and two-year follow-up images. For Subgroup 3 this choice was done because we considered pathologic myopia a long-standing disease, thus likely limiting the possibility to detect the first onset of the first atrophic or vitreomacular complications. 
Eyes complicated by MNV were treated by means of anti-VEGF injections accordingly with a pro-re-nata regimen. We calculated the number of administered injections over the two-year follow-up. 
The main outcome measure was the detection of statistically significant CT cutoffs associated with the three different Subgroups of eyes. Secondary outcomes included the assessment of the relationships between CT and DSM, CT and the subtype of CD, CT and MNV recurrence, DSM with or without CD, and each myopic Subgroup. 
We included only one eye for each subgroup of eyes. The study eye was selected considering the inclusion-exclusion criteria and the quality of the data. In case of similar conditions, the study eye was randomly selected. The fellow eye was never considered for the inclusion in the other subgroups. All the data were tested for normality distribution. Age and gender were considered as fixed factors. The statistical analyses were performed using frequency analysis, two-tailed t test, and one-way ANOVA with Bonferroni correction for multiple comparisons (SPSS, Chicago, IL, USA), with statistical significance set at P < 0.05. ROC analysis was used to assess the presence of significant CT cutoffs segregating the three subgroups of eyes. Tau-Kendall correlation analysis (SPSS) was used to assess the relationship among all the considered variables. 
Results
Overall Data
We inspected a database made by 398 eyes (398 patients). One-hundred ninety eyes (190 patients; mean age 68 ± 12 years) met the inclusion and exclusion criteria. The included eyes were classified as follows: Subgroup 1 (66 eyes; 40 female [61%]; mean age 69 ± 13 years), Subgroup 2 (72 eyes; 45 female (63%); mean age 67 ± 13 years) and Subgroup 3 (52 eyes; 33 female (63%); mean age 68 ± 12 years). All MNV recognized a type 2 component both on structural OCT and fluorescein angiography examinations. Examples for each Subgroup are shown in Figure 2. The mean axial length was 31.74 ± 2.01 mm, corresponding to a refractive correction of −13.0D ± 2.0D. The three subgroups were similar in terms of age, gender, and axial length distributions (P > 0.05). No age- and gender-related statistically significant effects have been observed for all the performed measures (all P > 0.05). LogMAR BCVA, CMT, and CT values are extensively reported in Table 1. For this part, the most interesting finding is the progressive reduction of CT values in all the subgroups from baseline to two-year follow-up (Table 1). LogMAR BCVA resulted stable in Subgroup 1 and Subgroup 3, whereas CMT was stable only in Subgroup 1. Considering all the collected variables, the overall interclass correlation coefficient value was 0.9 (range 0.86–0.98; P < 0.05). 
Figure 2.
 
The three myopic subgroups. For each subgroup, multicolor, blue autofluorescence and OCT images are shown. Subgroup 1 (A) is represented by high myopia without clinically relevant alterations. Subgroup 2 (B) is characterized by the onset of macular neovascularization with subretinal exudation. Subgroup 3 (C) represents high myopia complicated by nonneovascular myopic maculopathy. In this specific case, it is possible to observe a vertical dome-shape macula.
Figure 2.
 
The three myopic subgroups. For each subgroup, multicolor, blue autofluorescence and OCT images are shown. Subgroup 1 (A) is represented by high myopia without clinically relevant alterations. Subgroup 2 (B) is characterized by the onset of macular neovascularization with subretinal exudation. Subgroup 3 (C) represents high myopia complicated by nonneovascular myopic maculopathy. In this specific case, it is possible to observe a vertical dome-shape macula.
Table 1.
 
Demographic and Clinical Data
Table 1.
 
Demographic and Clinical Data
The Clinical Impact of CT
The frequencies of baseline CT values for each Subgroup are plotted in Figure 3 and extensively reported in Table 2. As seen in the bar plots (Fig. 4), baseline CT values are well segregated among the three myopic subgroups. The ROC analysis shows well how baseline CT is useful to detect statistically significant cutoffs associated with the risk of myopic complications (area under the curve = 0.85; standard error 0.04; confidence interval 0.78–0.92; P < 0.05) (Fig. 5). In particular, a baseline CT cutoff of 40 µm was significantly associated with the presence of myopic maculopathies, either considering MNV or nonneovascular maculopathy (sensitivity 0.83; specificity 0.74; 0 < 0.05). Furthermore, a baseline CT cutoff of 30 µm proved useful to segregate eyes complicated by MNV from eyes showing atrophy alone (Sensitivity 0.74; Specificity 0.68; 0 < 0.05). CT had a role to characterize the three myopic subgroups, showing a significant correlation either with axial length and refractive error (Tau-Kendall coefficient = 0.65; P < 0.05). However, no association between CT and both visual outcome and MNV recurrence was found (all P > 0.05). 
Figure 3.
 
Histogram plots of frequencies distribution of baseline choroidal thickness in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 3.
 
Histogram plots of frequencies distribution of baseline choroidal thickness in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Table 2.
 
Baseline Choroidal Thickness Frequencies in High Myopia
Table 2.
 
Baseline Choroidal Thickness Frequencies in High Myopia
Figure 4.
 
Bar plots of baseline choroidal thickness values (mean ± SD) in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 4.
 
Bar plots of baseline choroidal thickness values (mean ± SD) in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 5.
 
ROC analysis segregating myopic eyes without complications from eyes affected either by MNV or nonneovascular myopic maculopathy (area under the curve = 0.85; standard error = 0.04; confidence interval 0.78–0.92; P < 0.05).
Figure 5.
 
ROC analysis segregating myopic eyes without complications from eyes affected either by MNV or nonneovascular myopic maculopathy (area under the curve = 0.85; standard error = 0.04; confidence interval 0.78–0.92; P < 0.05).
High Myopia Without Complications Subgroup Analysis
DSM was found in 26 out of 66 eyes (39%). DSM results were distributed as follows: horizontal (10 out of 26 eyes [38%]), vertical (14 out of 26 eyes [54%]), and round (2 out of 26 eyes [8%]) (P < 0.05). We found no statistically significant differences among eyes with or without DSM. 
Among DSM eyes, 12 out of 26 eyes showed no CD (46%), whereas SDCD was found in 8 out of 26 eyes (31%) and PDCD in 6 out of 26 eyes (23%) (P < 0.05). We found no significant differences among these subgroups. No clinically relevant correlations characterized Subgroup 1. 
MNV Subgroup Analysis
For eyes complicated by MNV, the mean number of anti-VEGF intravitreal injections was 4 ± 2 for the first year and 2 ± 2 for the second year. MNV localization was so found: foveal (48 eyes [67%]), juxta-foveal (17 eyes [24%]), and extrafoveal (seven eyes [9%]). 
The presence of DSM was found in 33 out of 72 eyes (44%). DSM resulted distributed as follows: horizontal (six out of 33 eyes [18%]), vertical (11 out of 33 eyes [33%]), and round (16 out of 33 eyes [49%]) (P < 0.05). We found a statistically significant clinical difference among eyes with or without DSM, considering MNV recurrence during the first year. Indeed, MNV eyes without DSM underwent 4 ± 2 injections during the first year, with respect to DSM eyes treated with 3 ± 2 injections (P < 0.05). 
Among DSM eyes, six out of 33 eyes showed no CD (18%), whereas SDCD was found in 18 out of 33 eyes (55%) and PDCD in nine out of 33 eyes (27%) (P < 0.05). We found a significant difference among these subgroups considering the MNV localization. Indeed, the distribution of MNV was found as follows: DSM eyes without CD (four foveal MNV and two juxta-foveal MNV [67% and 33%, respectively]), DSM with SDCD (18 foveal MNV; 100%) and DSM with PDCD (two foveal MNV, three juxta-foveal MNV, and four extrafoveal MNV [22%, 33%, and 45%, respectively]) (P < 0.05). Eyes without DSM showed the following MNV distribution: 24 foveal MNV, 12 juxta-foveal MNV, and three extrafoveal MNV [62%, 31%, and 7%, respectively]). High MNV recurrence had a significantly negative impact on visual outcome (Tau-Kendall coefficient = 0.45; P < 0.05), as well as MNV localization (foveal, juxta-foveal and extrafoveal) (Tau-Kendall coefficient = 0.68; P < 0.05). 
Non-Neovascular Myopic Maculopathy Subgroup Analysis
DSM was found in 15 out of 52 eyes (29%). DSM results are distributed as follows: horizontal (eight out of 15 eyes [53%]), vertical (seven out of 15 eyes [47%]) and round (0 out of 15 eyes; 0%) (P < 0.05). We found no statistically significant clinical differences among eyes with or without DSM. 
Among DSM eyes, three out of 15 eyes showed no CD (20%), whereas SDCD was found in 0 out of 15 eyes (0%) and PDCD in 12 out of 15 eyes (80%) (P < 0.05). We found no significant differences among these subgroups. No significant correlations were found for Subgroup 3. 
Resuming DSM Characteristics in High Myopia Subgroups
The prevalence of DSM and the distribution of different DSM subtypes frequencies is reported in Table 3. Summing up these findings, the presence of DSM seemed to have an influence on high myopia. In Subgroup 1, vertical DSM represented the most frequent subtype (54% of cases), whereas round DSM highly characterized Subgroup 2 (49% of cases). With respect to Subgroup 3, there is a similar prevalence of horizontal and vertical DSM (53% and 47% of cases, respectively), although the most evident finding is the absence of round DSM subtype. Moreover, Subgroup 1 was characterized by the absence of CD in 46% of cases, whereas SDCD distinguished 55% of eyes belonging to Subgroup 2. The eyes characterized by SDCD showed foveal localization of the MNV in 100% of cases. Interestingly, SDCD was absent in Subgroup 3, whose eyes showed PDCD in 80% of cases. The distributions of MNV localization are plotted in Figure 6
Table 3.
 
Dome-Shaped Macula Analysis in High Myopia
Table 3.
 
Dome-Shaped Macula Analysis in High Myopia
Figure 6.
 
Distributions of MNV localization in high myopia. All the percentage data are separately plotted for eyes without DSM, eyes with DSM and no CD, eyes with DSM and SDCD, eyes with DSM and PDCD.
Figure 6.
 
Distributions of MNV localization in high myopia. All the percentage data are separately plotted for eyes without DSM, eyes with DSM and no CD, eyes with DSM and SDCD, eyes with DSM and PDCD.
Discussion
Myopia is nowadays considered a global epidemic. The estimated incidence for 2050 is at least 50% of worldwide population, with 10% of patients affected by high myopia.10 Considering the negative effects of high myopia on visual function,1,11 this rapid growth makes necessary the development of new strategies to prevent visual impairment and the onset of myopic-related complications. 
In the present article, we retrospectively analyzed a big cohort of eyes affected by high myopia, stratifying eyes without complications from eyes affected by myopic MNV and eyes complicated by pathologic myopia to enhance clinically relevant differences. The main result of this investigation regarded the clinical utility of choroidal assessment to potentially calculate the risk of onset of myopic complications and to assess visual outcome. CT proved useful to reach this goal, providing statistically significant cutoffs segregating the three subgroups of included eyes. In particular, a CT cutoff of 40 µm was significantly associated with the presence of neovascular or atrophic myopic maculopathies. Moreover, a CT < 30 µm significantly characterized the atrophic myopic maculopathy subgroup. Interestingly, myopic eyes complicated by MNV showed intermediate CT values with respect to high myopic eyes without complications and eyes affected by atrophic myopic maculopathy. This finding suggests that the presence of a thin choroid is a risk factor for MNV onset, as previously described2; however, a partially preserved choroidal structure is needed to favor the onset and growth of myopic MNV. In more detail, based on the findings of the present study, it is possible to assume that CT lower than 40 µm should be considered a major risk factor for the onset of myopic-related complications. The main reason for that may be related with the reduction of the choroidal vascular supply, leading to increased distress of the photoreceptors/RPE complex. We must acknowledge that we have not enough data to definitely assess the factors ruling the onset either of neovascular or atrophic complications in the CT range between 30 to 40 µm. However, we may hypothesize that a “partially thin choroid” is a fundamental factor to (I) induce the RPE distress; (II) stimulate VEGF release from RPE cells, and (III) provide the vascular substrate to favor the development of MNV. Conversely, the presence of an “extremely thin choroid,” namely with CT < 30 µm, is more associated with the onset of nonneovascular pathologic myopia. In this latter case, we may hypothesize that the above-described three requirements are not satisfied, thus favoring an atrophic evolution. CT tended to decrease after anti-VEGF injections, as already shown by previous article,12,13 although always maintaining higher values than nonneovascular pathologic myopia. The axial length is an undoubted risk factor for choroidal thinning. However, as shown by our findings, if at the same axial length there is a thicker choroid, the trophic support is guaranteed, and the high myopia is not associated with the onset of complications. 
Another major factor evaluated in the present study was DSM. This inward bulging of the macula is present in 9.3% to 20.1% of high myopic eyes.9,14 The pathogenesis of DSM is still unknown, and the clinical impact of this structural OCT finding is unclear. Indeed, the literature shows no agreement regarding the possible negative impact of DSM on the course of high myopia; DSM effect on CT values is also matter of debate.15,16 Also, thanks to the classification recently proposed by Zhao and colleagues,9 in the present study we found a significant clinical impact of DSM on high myopia. Indeed, the high myopia without complications subgroup was characterized by 39% of cases showing DSM, with 54% of cases represented by vertical DSM and 48% of cases showing no CD. The prevalence of DSM was similar in eyes affected by MNV, although 49% of cases were characterized by round DSM, and 55% of cases showed SDCD. Interestingly, eyes with DSM showed a slightly lower MNV recurrence than eyes without DSM. This might suggest a lower choroidal support to the MNV growth in DSM eyes. Moreover, 100% of DSM cases showing SDCD were characterized by the foveal localization of the MNV. Conversely, DSM eyes with PDCD had a trend of extrafoveal localization of the MNV. Although the number of eyes affected by extrafoveal MNV is too low to draw definite conclusions, our data might suggest a different pathogenic mechanism characterizing extrafoveal MNV. We could hypothesize not the same mechanical forces or Bruch's membrane weakening or ruptures as major pathogenic factors of extrafoveal MNV. However, further studies are warranted to assess in deep the onset and progression profiles of each type of myopic MNV. With respect to the nonneovascular pathologic myopia subgroup, the overall presence was 29% of cases, with half cases characterized by horizontal DSM and half cases showing vertical DSM. It is worth of notice that no cases showed round DSM. In addition, most of the eyes belonging to this latter subgroup were characterized by PDCD (80% of cases). If compared with the findings provided by Zhao and colleagues,9 our data showed some discrepancies probably related with the different patients’ sampling and categorization. However, there is an agreement regarding the possible influence of the mechanical forces caused by DSM on the course of high myopia. 
Although all these findings cannot be considered conclusive, it is strongly suggested that the presence of peculiar morphologic features the three subgroup of high myopic eyes. If confirmed by further prospective investigations, the tracing of specific choroidal profiles with or without DSM might be useful to stratify the risk of onset of myopic-related complications and to personalize the follow-up strategy of high myopic eyes. 
We are aware our study is potentially affected by several limitations, mainly related to the retrospective design. Indeed, much more detailed analyses, including the evolution of the axial length over time, the precise timing of choroidal changes, and others could not be performed, thus requiring future prospective investigations. The lack of age- and gender-related effects could be related to the high variability of the samples. Also in this case, these effects would benefit from dedicated investigations. Furthermore, we are aware that many additional morphological features may characterize DSM eyes. However, with respect to the present study, one main goal was only to assess whether DMS prevalence and subtypes might have different distribution among the considered subgroups of myopic eyes. Also in this case, more detailed evaluations of DSM characteristics would benefit from further specifically designed investigations.1721 Moreover, the imaging-based assessment of high myopic eyes is intrinsically difficult because of the wide modifications caused by the enhanced curvature of the eye. This makes challenging the adoption of more sophisticated quantitative approaches, because the risk of artifacts and misinterpretation is high.22 Furthermore, all of our hypotheses and speculations will benefit from the conduction of further prospective studies to draw definite conclusions regarding the role of choroidal and DSM assessment in the high myopia pathogenesis and course. 
In conclusion, our study highlighted CT and DSM assessments as clinically relevant approaches to stratify different subgroups of high myopic eyes. DSM is a frequent finding in myopic MNV subtype. When DSM is present, vertical subtype with SDCD is the most common combination in myopic MNV subtype, whereas nonneovascular pathologic myopia is mainly characterized by PDCD. The statistically significant association of choroidal metrics and DSM subtypes with the presence and localization of myopic MNV, as well as with nonneovascular pathologic myopia suggests their potential role to improve the diagnostic workup and treatment strategies in the high myopia clinical setting. 
Acknowledgments
Disclosure: A. Arrigo, None; E. Aragona, None; L. Bianco, None; A. Antropoli, None; A. Saladino, None; F. Bandello, Alcon (C), Alimera Sciences (C), Allergan Inc. (C), Farmila-Thea (C), Bayer Shering-Pharma (C), Bausch and Lomb (C), Genentech (C), Hoffmann-La-Roche (C), NovagaliPharma (C), Novartis (C), Sanofi-Aventis (C), Thrombogenics (C), Zeiss (C); M. Battaglia Parodi, None 
References
Wong TY, Ferreira A, Hughes R, Carter G, Mitchell P. Epidemiology and disease burden of pathologic myopia and myopic choroidal neovascularization: an evidence-based systematic review. Am J Ophthalmol. 2014; 157: 9–25. [CrossRef] [PubMed]
Wang S, Wang Y, Gao X, Qian N, Zhuo Y. Choroidal thickness and high myopia: a cross-sectional study and meta-analysis. BMC Ophthalmol. 2015; 15: 70. [CrossRef] [PubMed]
Lee JH, Lee SC, Kim SH, et al. Choroidal thickness and chorioretinal atrophy in myopic choroidal neovascularization with anti-vascular endothelial growth factor therapy. Retina. 2017; 37: 1516–1522. [CrossRef] [PubMed]
Jain M, Gopal L, Padhi TR. Dome-shaped maculopathy: a review. Eye (Lond). 2021; 35: 2458–2467. [CrossRef] [PubMed]
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. [CrossRef] [PubMed]
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. [CrossRef] [PubMed]
Ellabban AA, Tsujikawa A, Matsumoto A, et al. Three-dimensional tomographic features of dome-shaped macula by swept-source optical coherence tomography. Am J Ophthalmol. 2013; 155: 320–328. [CrossRef] [PubMed]
Ohsugi H, Ikuno Y, Oshima K, Yamauchi T, Tabuchi H. Morphologic characteristics of macular complications of a dome-shaped macula determined by swept-source optical coherence tomography. Am J Ophthalmol. 2014; 158: 162–170. [CrossRef] [PubMed]
Zhao X, Lian P, Li S, et al. Patterns of choroidal deepening in highly myopic eyes with dome-shaped macula. Curr Eye Res. 2020; 45: 1017–1023. [CrossRef] [PubMed]
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. [CrossRef] [PubMed]
Smith TS, Frick KD, Holden BA, Fricke TR, Naidoo KS. Potential lost productivity resulting from the global burden of uncorrected refractive error. Bull World Health Organ. 2009; 87: 431–437. [CrossRef] [PubMed]
Farinha CL, Baltar AS, Nunes SG, et al. Choroidal thickness after treatment for myopic choroidal neovascularization. Eur J Ophthalmol. 2013; 23(6): 887–898. [CrossRef] [PubMed]
Ahn SJ, Park KH, Woo SJ. Subfoveal choroidal thickness changes following anti-vascular endothelial growth factor therapy in myopic choroidal neovascularization. Invest Ophthalmol Vis Sci. 2015; 56(10): 5794–5800. [CrossRef] [PubMed]
Liang IC, Shimada N, Tanaka Y, et al. Comparison of clinical features in highly myopic eyes with and without a dome-shaped macula. Ophthalmology. 2015; 122: 1591–1600. [CrossRef] [PubMed]
Imamura Y, Iida T, Maruko I, Zweifel SA, Spaide RF. Enhanced depth imaging optical coherence tomography of the sclera in dome-shaped macula. Am J Ophthalmol. 2011; 151: 297–302. [CrossRef] [PubMed]
Zhao X, Ding X, Lyu C, et al. Observational study of clinical characteristics of dome-shaped macula in Chinese Han with high myopia at Zhongshan Ophthalmic Centre. BMJ Open. 2018; 8(12): e021887. [CrossRef] [PubMed]
Soudier G, Gaudric A, Gualino V, et al. Long-term evolution of dome-shaped macula: increased macular bulge is associated with extended macular atrophy. Retina. 2016; 36(5): 944–952. [CrossRef] [PubMed]
García-Ben A, Sanchez MJM, Gómez AG, García-Basterra I, García AS, García-Campos JM. Factors associated with serous retinal detachment in highly myopic eyes with vertical oval-shaped dome. Retina. 2019; 39: 587–593. [CrossRef] [PubMed]
García-Ben A, Garcia-Basterra I, González-Gómez A, et al. Comparison of long-term clinical evolution in highly myopic eyes with vertical oval-shaped dome with or without untreated serous retinal detachment. Br J Ophthalmol. 2019; 103: 385–389. [CrossRef] [PubMed]
Dormegny L, Liu X, Philippakis E, et al. Evolution of dome-shaped macula is due to differential elongation of the eye predominant in the peri-dome region. Am J Ophthalmol. 2021; 224: 18–29. [CrossRef] [PubMed]
Negrier P, Couturier A, Gaucher D, et al. Choroidal thickness and vessel pattern in myopic eyes with dome-shaped macula. Br J Ophthalmol. 2022; 106: 1730–1735. [CrossRef] [PubMed]
Arrigo A, Aragona E, Battaglia Parodi M, Bandello F. Quantitative approaches in multimodal fundus imaging: state of the art and future perspectives. Prog Retin Eye Res. 2023; 92: 101111. [CrossRef] [PubMed]
Figure 1.
 
The three patterns of choroidal changes in DSM. (A) A case of high myopia without DSM. To evaluate the presence of CD, choroidal thickness measure was performed at the top of the dome and the bottom of the dome. (B) A case of DSM with no CD, showing uniform choroidal thickness at the top (blue arrow) and the bottom (red arrows) of the dome. (C) A case of SDCD, where the choroid resulted thicker at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows). (D) A case of PDCD, where the choroid resulted thinner at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows).
Figure 1.
 
The three patterns of choroidal changes in DSM. (A) A case of high myopia without DSM. To evaluate the presence of CD, choroidal thickness measure was performed at the top of the dome and the bottom of the dome. (B) A case of DSM with no CD, showing uniform choroidal thickness at the top (blue arrow) and the bottom (red arrows) of the dome. (C) A case of SDCD, where the choroid resulted thicker at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows). (D) A case of PDCD, where the choroid resulted thinner at the top of the dome (blue arrow) with respect to the bottom of the dome (red arrows).
Figure 2.
 
The three myopic subgroups. For each subgroup, multicolor, blue autofluorescence and OCT images are shown. Subgroup 1 (A) is represented by high myopia without clinically relevant alterations. Subgroup 2 (B) is characterized by the onset of macular neovascularization with subretinal exudation. Subgroup 3 (C) represents high myopia complicated by nonneovascular myopic maculopathy. In this specific case, it is possible to observe a vertical dome-shape macula.
Figure 2.
 
The three myopic subgroups. For each subgroup, multicolor, blue autofluorescence and OCT images are shown. Subgroup 1 (A) is represented by high myopia without clinically relevant alterations. Subgroup 2 (B) is characterized by the onset of macular neovascularization with subretinal exudation. Subgroup 3 (C) represents high myopia complicated by nonneovascular myopic maculopathy. In this specific case, it is possible to observe a vertical dome-shape macula.
Figure 3.
 
Histogram plots of frequencies distribution of baseline choroidal thickness in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 3.
 
Histogram plots of frequencies distribution of baseline choroidal thickness in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 4.
 
Bar plots of baseline choroidal thickness values (mean ± SD) in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 4.
 
Bar plots of baseline choroidal thickness values (mean ± SD) in high myopia. All the data are separately reported for Subgroup 1 (myopia without complications) (green), Subgroup 2 (myopic choroidal neovascularization) (red) and Subgroup 3 (nonneovascular myopic maculopathy) (blue).
Figure 5.
 
ROC analysis segregating myopic eyes without complications from eyes affected either by MNV or nonneovascular myopic maculopathy (area under the curve = 0.85; standard error = 0.04; confidence interval 0.78–0.92; P < 0.05).
Figure 5.
 
ROC analysis segregating myopic eyes without complications from eyes affected either by MNV or nonneovascular myopic maculopathy (area under the curve = 0.85; standard error = 0.04; confidence interval 0.78–0.92; P < 0.05).
Figure 6.
 
Distributions of MNV localization in high myopia. All the percentage data are separately plotted for eyes without DSM, eyes with DSM and no CD, eyes with DSM and SDCD, eyes with DSM and PDCD.
Figure 6.
 
Distributions of MNV localization in high myopia. All the percentage data are separately plotted for eyes without DSM, eyes with DSM and no CD, eyes with DSM and SDCD, eyes with DSM and PDCD.
Table 1.
 
Demographic and Clinical Data
Table 1.
 
Demographic and Clinical Data
Table 2.
 
Baseline Choroidal Thickness Frequencies in High Myopia
Table 2.
 
Baseline Choroidal Thickness Frequencies in High Myopia
Table 3.
 
Dome-Shaped Macula Analysis in High Myopia
Table 3.
 
Dome-Shaped Macula Analysis in High Myopia
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