Translate this page into:
Association of fundus changes with myopia severity: A prospective study
-
Received: ,
Accepted: ,
How to cite this article: Patel AQ, Walinjkar JA. Association of fundus changes with myopia severity: A prospective study. J Ophthalmic Res Pract. 2026;4:25-30. doi: 10.25259/JORP_35_2025
Abstract
Objectives:
The aim of the study is to evaluate and compare the spectrum of fundus changes across varying degrees of myopia.
Material and Methods:
A prospective observational study was conducted between December 2024 and June 2025. This study included 122 eyes of 71 patients with distinct degrees of myopia. The American Optometric Association classification of myopia (low: Up to −3.00D, moderate −3.00–−6.00D, high: > −6.00D) was utilized for categorization. All the individuals underwent a comprehensive ophthalmological examination. Fundus features across different degrees of myopia were assessed and compared. Further fundus findings were grouped as posterior pole findings, peripheral findings, and vitreous findings. Data were collected using electronic medical record software. Following data collection, statistical analysis was performed employing the Chi-square test while considering P < 0.05 to be statistically significant.
Results:
Retinal and vitreous degenerative changes were noted in all groups of myopia. The prevalence and severity increased with rising levels of myopia. Statistically significant association was found between myopia severity and findings such as peripapillary atrophy, posterior staphyloma, lattice degeneration (LD), white without pressure (WWOP) areas, and chorioretinal atrophy (P < 0.05). Vitreous changes, including posterior vitreous detachment, were predominantly seen in moderate to high myopes. Peripheral findings such as LD and WWOP were found in all the groups and with a comparable rate of incidence.
Conclusion:
Significant correlation was observed between the degree of myopia and the incidence of retinal and vitreous degeneration. Fundus changes are present in all grades of myopia. These findings emphasize the need for regular monitoring in myopic individuals; early identification of these alterations is vital to prevent associated sight-threatening complications in myopes.
Keywords
Association
Fundus features
Myopia
Periphery
Posterior pole
Vitreous degeneration
INTRODUCTION
Myopia or nearsightedness refers to a multifaceted refractive condition of the eye wherein distant objects appear blurry.[1] Causes of myopia include excessive elongation of the eyeball (axial myopia), abnormal progression of corneal curvature (curvatural myopia), or refractive index of lens (index myopia).[2] Epidemiological studies suggest that genetic factors and environmental influences play a significant role in the development of myopia.[3]
Myopia has become a progressive concern for most developing countries.[2,3] As per the International Myopia Institute white paper series, 30% population across the globe is afflicted with myopia.[4] A comprehensive meta-analysis by Agarwal et al.[5] included 59 studies from 1980 to 2019 in which they found that the prevalence of myopia was 7.5% in school-going children (5–15 years). Another meta-analysis by Priscilla and Verkicharla[6] predicted the estimated rise in myopia development in India to be 48.14% by 2050 in the similar age group. Reduced outdoor activities, increased screen time, and prolonged near activities driven by academic demands have been identified as key risk factors in school-going children.[7] Many studies have shown a slight female preponderance in myopia.[8]
Treatment of myopia mainly focuses on correcting and slowing down the progression. It can be corrected through spectacles, contact lenses, and refractive surgical procedures,[9] although fundus changes due to myopia need special attention and monitoring. Common fundus changes associated with myopia are lattice degeneration (LD), peripapillary atrophy (PPA), myopic macular degeneration (MMD), rhegmatogenous retinal detachment, and early vitreous degeneration.[10] The present study was undertaken to elicit and compare the fundus changes across different degrees of myopia, with the goal of identifying early degenerative changes that may progress over time.
MATERIAL AND METHODS
This was a prospective observational study conducted at a tertiary eye care center in Mumbai, from December 2024 to June 2025. Patients were selected using random sampling with informed written consent from the subjects. The study included patients with myopic refractive error and clear media, allowing fundus examination. Confounding factors that could influence the results such as age-related changes, media opacities, pseudophakia, aphakia, previous history of refractive surgery, retinal detachment surgery, a known case of inherited retinal disorder, retinopathy of prematurity, displaced crystalline/intraocular lens, and keratoconus were excluded.
A total of 122 eyes of 71 individuals were included in this study. These individuals were further segregated into three groups based on the different degrees of myopia. The division was made on the basis of the American Optometric Association (AOA) classification of myopia:
Low myopia: up to −3.00D
Moderate myopia: −3.00D–−6.00D
High myopia: > −6.00D.
During categorization, the spherical component of refractive error was taken into consideration, and the cylindrical component was excluded.
All the patients underwent a thorough ophthalmic evaluation. The process included the following steps:
Detailed history (including family history)
Visual acuity using the LogMAR acuity chart
Objective and subjective refraction
Anterior segment evaluation through slit lamp biomicroscopy
Dilated fundus evaluation through indirect ophthalmoscopy
Fundus photography (for documentation)
Optical coherence tomography (if required).
Fundus findings were systematically evaluated in all the enrolled individuals and subsequently categorized into three anatomical regions: Posterior pole, peripheral retina, and vitreous. This classification allowed for a structured analysis of the fundus changes associated with varying degrees of myopia. Continuous variables such as age, refractive error, and best corrected visual acuity (BCVA) were summarized as mean ± standard deviation (SD), while categorical variables were presented as frequency counts and percentages and illustrated using appropriate graphs and tables. Data analysis was performed by utilizing IBM Statistical Package for the Social Sciences software version 30 (IBM Corp., Armonk, NY, USA). Chi-square test was applied to compare categorical variables across the grades of myopia. A P < 0.05 was considered statistically significant.
RESULTS
Among the 122 eyes evaluated, low myopia accounted for 48.3%, moderate myopia for 23.7%, and high myopia for 27.8%. The low myopia group (n = 59) had a mean age of 26.1 ± 12.0 years (mean ± SD) and included 44 males and 15 females. The mean spherical error was −1.80D ± 0.85D, and the mean BCVA was 0.03 ± 0.09 log units. The moderate myopia group (n = 29) had a mean age of 30.3 ± 11.5 years with 21 males and 8 females. The mean spherical error was −4.52D ± 0.92D, and mean BCVA was 0.10 ± 0.20 log units. The high myopia (n = 34) had a mean age of 33.1 ± 15.3, comprising 23 males and 11 females. The mean spherical error was −10.61D ± 4.75D, and mean BCVA was 0.30 ± 0.49 log units. All the demographic data have been summarized in Tables 1 and 2. Average age showed an increasing trend with the severity of myopia [Graph 1]. In our study, the incidence of myopia in males (72.13%) was more than in females (27.86%). With a particularly higher proportion in the low myopia group [Graph 2]. Mean BCVA progressively worsened from low to high myopia groups [Graph 3].
| Group | Total eyes | Average age | Male | Female | Mean spherical error | Mean BCVA |
|---|---|---|---|---|---|---|
| Low myopia | 59 | 26.1 | 44 | 15 | −1.80 D | 0.03 |
| Moderate myopia | 29 | 30.3 | 21 | 8 | −4.52 D | 0.10 |
| High myopia | 34 | 33.1 | 23 | 11 | −10.61 D | 0.30 |
BCVA: Best-corrected visual acuity
| Laterality | Total | Percentage |
|---|---|---|
| Bilateral | 51 | 71.8 |
| Unilateral | 20 | 28.1 |
| Eye involved | ||
| Right eye | 59 | 48.3 |
| Left eye | 63 | 51.6 |
The distribution of retinal findings across three groups was analyzed and compared [Tables 3-5]. Statistical analysis using the Chi-square test confirmed significant associations between the severity of myopia and the presence of specific retinal features across all three anatomical zones evaluated.
| Posterior pole findings | Degree of myopia | ||
|---|---|---|---|
| Low | Moderate | High | |
| Pigment alterations | 2 | 1 | 3 |
| Peripapillary atrophy | 1 | 6 | 15 |
| Posterior staphyloma | 0 | 1 | 5 |
| Myopic macular degeneration | 0 | 2 | 8 |
| Temporal crescent | 0 | 0 | 3 |
| Situs inversus of the optic disc | 0 | 0 | 2 |
| Chorioretinal atrophy | 0 | 5 | 11 |
| Peripheral retinal findings | Degree of myopia | ||
|---|---|---|---|
| Low | Moderate | High | |
| Lattice degeneration | 7 | 9 | 16 |
| White without pressure | 7 | 3 | 9 |
| Horseshoe tear | 0 | 0 | 1 |
| Retinal hole | 1 | 1 | 5 |
| Snowflake degeneration | 0 | 0 | 2 |
| Retinal detachment | 1 | 1 | 1 |
| Vitreous findings | Degree of myopia | ||
|---|---|---|---|
| Low | Moderate | High | |
| Posterior vitreous detachment | 0 | 0 | 3 |
| Vitreous condensation | 0 | 1 | 2 |
Posterior pole changes, including PPA, posterior staphyloma (PS), pigment alterations (PA), and MMD, were predominantly observed in the high myopia group, with a statistically significant difference compared to the low and moderate myopia groups (P < 0.05). These changes were infrequent in low myopia and appeared with increasing frequency as the severity of myopia increased.
Peripheral retinal findings, particularly LD and white without pressure (WWOP), were prevalent in all three groups. These changes also showed a positive correlation with the degree of myopia, and statistical analysis using the Chi-square test indicated a significant association (P < 0.05).
Vitreous findings such as posterior vitreous detachment (PVD) and vitreous condensation were more prevalent in high myopes but absent in low myopia. Although all these findings were present to some extent in moderate myopes, their incidence was notably higher among those with high myopia. The observed differences were statistically significant. Group comparison and Chi-square test results are summarized in Table 3.
Retinal and vitreous changes were found in all degrees of myopia [Graph 4]. Even among eyes with low myopia, findings such as PAs (3.4%), LD, and WWOP (11.9%) were documented. The frequency and severity of changes, however, increased with higher degrees of myopia.
Statistically significant differences were observed in the prevalence of several fundus findings across the three myopia groups. As shown in Table 6, PPA, MMD, PS, chorioretinal atrophy (CRA), and LD exhibited significant associations with the degree of myopia (P < 0.05), as confirmed by Chi-square test.
| Findings | Chi-square | P-value |
|---|---|---|
| PPA | 26.44 | <0.001 |
| CRA | 20.38 | <0.001 |
| MMD | 15.96 | 0.0003 |
| LD | 14.26 | 0.0008 |
| PS | 10.15 | 0.0062 |
| TC | 7.96 | 0.0187 |
| PVD | 7.96 | 0.0187 |
| HOLE | 7.12 | 0.0284 |
| SID | 5.26 | 0.072 |
| SD | 5.26 | 0.072 |
| WWOP | 4.29 | 0.117 |
| VIT COND | 3.27 | 0.1953 |
| HST | 2.61 | 0.2712 |
| PIGM A | 1.54 | 0.4636 |
| RD | 0.29 | 0.8629 |
P<0.05 statistically significant. PPA: Peripapillary atrophy, CRA: Chorioretinal atrophy, MMD: Myopic macular degeneration, PS: Posterior staphyloma, TC: Temporal crescent, SID: Situs inversus of optic disc, LD: Lattice degeneration, PVD: Posterior vitreous detachment, SD: Snowflake degeneration, WWOP: White without pressure, VIT COND: Vitreous condensation, HST: Horseshoe tear, PIGM A: Pigment alterations, RD: Retinal detachment
The descriptive statistics for these significant findings are provided in Table 7. PPA was noted in 1.7% of eyes with low myopia, increasing to 20.7% in moderate and 44.1% in high myopia. Similarly, MMD was absent in low myopia but present in 6.9% of moderate and 23.5% of high myopia cases. PS showed a marked increase from 0% in low myopia to 14.7% in high myopes. LD was found in 15.2%, 3%, and 47.1% of eyes with low, moderate, and high myopia, respectively. CRA was also significantly more common in high myopia. Vitreous changes, although less frequent, were primarily seen in the high myopia group.
| Finding | Low myopia frequency | Low myopia % | Moderate myopia frequency | Moderate myopia % | High myopia frequency | High myopia % |
|---|---|---|---|---|---|---|
| PIGM A | 2 | 3.4 | 1 | 3.4 | 3 | 8.8 |
| PPA | 1 | 1.7 | 6 | 20.7 | 15 | 44.1 |
| PS | 0 | 0 | 1 | 3.4 | 5 | 14.7 |
| MMD | 0 | 0 | 2 | 6.9 | 8 | 23.5 |
| TC | 0 | 0 | 0 | 0 | 3 | 8.8 |
| SID | 0 | 0 | 0 | 0 | 2 | 5.9 |
| CRA | 0 | 0 | 5 | 17.2 | 11 | 32.4 |
| LD | 7 | 11.9 | 9 | 31 | 16 | 47.1 |
| WWOP | 7 | 11.9 | 3 | 10.3 | 9 | 26.5 |
| HST | 0 | 0 | 0 | 0 | 1 | 2.9 |
| HOLE | 1 | 1.7 | 1 | 3.4 | 5 | 14.7 |
| SD | 0 | 0 | 0 | 0 | 2 | 5.9 |
| RD | 1 | 1.7 | 1 | 3.4 | 1 | 2.9 |
| PVD | 0 | 0 | 0 | 0 | 3 | 8.8 |
| VIT COND | 0 | 0 | 1 | 3.4 | 2 | 5.9 |
PIGM A: Pigment alterations, PPA: Peripapillary atrophy, PS: Posterior staphyloma, CRA: Chorioretinal atrophy, MMD: Myopic macular degeneration, TC: Temporal crescent, SID: Situs inversus of optic disc, LD: Lattice degeneration, PVD: Posterior vitreous detachment, SD: Snowflake degeneration, WWOP: White without pressure, VIT COND: Vitreous condensation, HST: Horseshoe tear, RD: Retinal detachment
PVD was observed in 8.8% of high myopia cases and vitreous condensation in 5.9%.
Statistical analysis using the Chi-square test confirmed significant associations between the severity of myopia and the presence of specific retinal features across all three anatomical zones evaluated. The results align with prior literature emphasizing changes in high myopia. Notable fundus alterations in low and moderate warrant equal attention.
Literature review
The study highlights the spectrum of retinal and vitreous changes associated with increasing degrees of myopia, confirming a statistically significant association between higher refractive errors and the prevalence of posterior pole, peripheral retinal, and vitreous degenerations. While high myopia is widely recognized for its association with pathological changes, our findings reveal that retinal changes are not confined to high myopia. Early degenerative changes were observed even in low and moderate-myopic eyes.
This study also demonstrated that the greater incidence of myopia was observed in the age group <20 years (n = 33), followed closely by those in the 21–30 and 31–40 age groups (n = 32). This pattern emphasizes the early manifestation of myopia, supporting the global epidemiological concerns indicating the rising prevalence of myopia in childhood and adolescence.[11] The clustering of cases in younger age groups may reflect changing lifestyle factors.[12] These findings further reinforce the need for early screening and longitudinal monitoring of young myopes, even in the lower refractive categories, to detect and manage fundus changes before they progress to more severe complications.
The key methodological strength of this study is the use of the AOA classification to define degrees of myopia. In contrast to many prior studies that apply arbitrary or variable cutoffs for classifying myopia, our strict adherence to AOA definitions (low ≤ −3.00D, moderate −3.00D–−6.00D, high > −6.00D) lends greater standardization, reproducibility, and comparability to our results within the broader ophthalmic research community.[13,14]
Posterior pole changes, particularly PPA, MMD, PS, and CRA, were strongly correlated with high myopia. These changes likely result from scleral stretching and choroidal thinning, consistent with current understanding of pathological myopia.[15] Peripheral findings such as LD and WWOP were among the most frequently encountered peripheral findings. Importantly, these were observed even in the low myopia group, with LD present in 11.9% and WWOP in 11.9% of eyes. This was comparable to their prevalence in moderate myopia (LD: 31%, WWOP: 10.3%) and high myopia (LD: 47.1%, WWOP: 26.5%). The similar incidence in moderate and high groups, and even notable occurrence in low myopes, suggests that peripheral retinal degeneration may begin early in the course of myopic progression. LD is one of the well-established risk factors for retinal detachment.[16] This reinforces the need for proactive surveillance even in patients with low and moderate myopia.Notably, we identified several underreported or less commonly discussed findings in the literature, including situs inversus of the optic disc, snowflake degeneration, and vitreous condensation. These features, though infrequent, were predominantly observed in moderate to high myopia and may reflect early structural remodeling of the posterior segment or vitreous. Their documentation adds valuable insight into the broader clinical spectrum of myopia-related degeneration.
While the presence of degenerative features in high myopia was expected, this study demonstrates that low and moderate myopia are not exempt from early pathological changes. Detecting and documenting these early alterations is crucial for risk stratification and developing tailored follow-up protocols.
CONCLUSION
The findings underscore the importance of regular and dilated retinal evaluation in individuals with moderate to high myopia to facilitate early detection and timely intervention. Awareness of the specific retinal features associated with different degrees of myopia can aid clinicians in risk stratification and tailored follow-up protocols, potentially preventing vision-threatening complications in this vulnerable population.
Author contributions:
AP, JW: Design, definition of intellectual content, literature search, clinical studies, data acquisition, manuscript preparation, manuscript editing, manuscript review, and guarantor.
Ethical approval:
Institutional Review Board approval is not required as this is a prospective observational study evaluating outcomes.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Updates of pathologic myopia. Prog Retin Eye Res. 2016;52:156-87.
- [CrossRef] [PubMed] [Google Scholar]
- IMI-defining and classifying myopia: A proposed set of standards for clinical and epidemiologic studies. Invest Ophthalmol Vis Sci. 2019;60:20-30.
- [CrossRef] [PubMed] [Google Scholar]
- Genetic and environmental effects on myopia development and progression. Eye (Lond). 2014;28:126-33.
- [CrossRef] [PubMed] [Google Scholar]
- Editorial: International myopia institute white paper series 2023. Invest Ophthalmol Vis Sci. 2023;64:1.
- [CrossRef] [PubMed] [Google Scholar]
- Prevalence of myopia in Indian school children: Meta-analysis of last four decades. PLoS One. 2020;15:240750.
- [CrossRef] [PubMed] [Google Scholar]
- Time trends on the prevalence of myopia in India-a prediction model for 2050. Ophthalmic Physiol Opt. 2021;41:466-74.
- [CrossRef] [PubMed] [Google Scholar]
- Prevalence of refractive errors among school-going children in a multistate study in India. Br J Ophthalmol. 2023;108:143-51.
- [CrossRef] [PubMed] [Google Scholar]
- Prevalence of myopia among urban and suburban school children in Tamil Nadu, South India: Findings from the Sankara Nethralaya Tamil Nadu essilor myopia (STEM) study. Ophthalmic Physiol Opt. 2022;42:345-57.
- [CrossRef] [PubMed] [Google Scholar]
- Fundus changes in high myopia in relation to axial length of the globe. J Pharm Bioallied Sci. 2022;14:649-53.
- [CrossRef] [PubMed] [Google Scholar]
- Myopia among children and adolescents: An epidemiological study in Fuzhou City. Front Pediatr. 2023;11:1161329.
- [CrossRef] [PubMed] [Google Scholar]
- Long use of digital devices as a risk factor that causes myopia occurrence in schoolchildren. Health Risk Anal. 2020;4:77-84.
- [CrossRef] [Google Scholar]
- Clinical analysis of fundus changes in myopia. Ind J Sci Technol. 2015;8:1-6.
- [CrossRef] [Google Scholar]
- Correlation of fundus changes in relation to refractive error in patients with myopia-a clinical prospective study. J Evid Based Med Healthc. 2018;5:233-6.
- [CrossRef] [Google Scholar]
- Long-term pattern of progression of myopic maculopathy: A natural history study. Ophthalmology. 2010;117:1595-611. 1611.e1-4
- [CrossRef] [PubMed] [Google Scholar]
- Risk of retinal detachment in patients with lattice degeneration. Jpn J Ophthalmol. 1998;42:308-13.
- [CrossRef] [PubMed] [Google Scholar]