Pathways to Patchy Atrophy in High Myopia: Precursor Patterns, Structural Characteristics, and Long-Term Outcomes.

Résumé

OBJECTIVE: To characterize distinct precursor patterns associated with the development of patchy atrophy (PA) in highly myopic eyes and to describe their structural evolution and clinical outcomes over time.

DESIGN: A retrospective multicenter cohort study.

PARTICIPANTS: Highly myopic patients with documented onset of PAs and at least 3 months of multimodal imaging (MMI) prior to the PA development.

METHODS: Clinical, demographic, and MMI findings were retrospectively collected from 3 tertiary referral centers. Based on MMI findings preceding PA onset, eyes were categorized into 3 patterns: (1) inflammatory PAs in the context of punctate inner choroidopathy; (2) neovascular PAs, associated with extrafoveal macular neovascularization (MNV); and (3) idiopathic PAs, in the absence of identifiable inflammatory or neovascular precursor lesions.

MAIN OUTCOME MEASURES: Precursor patterns, clinical and MMI characteristics, clinical complication profile, and atrophy growth rate (AGR).

RESULTS: The study included 103 eyes (84 patients; 28 [27%] men) with a mean (standard deviation) age of 62 (13.4) years and mean refractive error of -13.2 (5.8) diopters at PA onset. Median observation periods prior to PA onset and post-PA follow-up were 2.1 years (interquartile range 5.20) and 3.44 years (interquartile range 7.23), respectively. Inflammatory PAs were detected in 33 (32%) eyes, neovascular PAs in 9 (9%) eyes, and 61 eyes (59%) had idiopathic PAs. Number of pre-existing PAs at baseline was the highest in inflammatory PAs (6.1 ± 6.4), followed by neovascular PAs (1.6 ± 1.1) and idiopathic PAs (1.5 ± 1.1; P < 0.001). Late-stage complications, including MNV (P < 0.001), subretinal fibrosis (P < 0.001), and macular atrophy (P = 0.01), occurred more frequently in inflammatory and neovascular PA than in idiopathic PA. Exploratory tree-based analysis identified baseline lesion number as a key feature distinguishing inflammatory PAs from idiopathic PAs. Mean AGR in the overall cohort was 0.73 ± 1.06 mm2/year (95% confidence interval, 0.52-0.94), with progression fastest in inflammatory PAs (1.3 ± 1.4 mm2/year), followed by neovascular PAs (0.7 ± 0.7 mm2/year) and slowest in idiopathic PAs (0.4 ± 0.7 mm2/year; P < 0.001). Higher baseline lesion number was associated with faster AGR (P = 0.005).

CONCLUSIONS: Patchy atrophies in highly myopic eyes develop with 3 precursor patterns (inflammatory, neovascular, and idiopathic) and differ in structural characteristics, atrophy progression, and complication profile. Recognition of PA patterns may improve clinical assessment of highly myopic eyes.

FINANCIAL DISCLOSURES: The authors have no proprietary or commercial interest in any materials discussed in this article.