5

Assessment and Recommendation of a 47-year-old Patient

with Pathologic Myopia OU and Presenile Cataract OD

A Research Proposal
Presented to the
Faculty of the College of Optometry
Southwestern University PHINMA

In partial Fulfillment
Of the Requirements for the Subject:
OPT 032: Low Vision
Optometry Laboratory

By:
Adrias, Gracel Cassandra
Banquirigo, Aprilyn D.
Gocotano, Wayne B.
Magallanes, Lalaine Jan B.
Mariño, Jarilou J.
Revilla, Peter Mari C.
Saylon, Brunette Ge D.

Dr. Angelica Faye Salcedo Sanchez

Research Adviser

February 2023
ABSTRACT

Pathologic myopia is a major cause of visual impairment worldwide, defined by a presence of

typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or
more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high
myopia, however its complications especially posterior staphyloma can also occur in eyes
without high myopia. According to the IMI, pathologic myopia is an excessive axial elongation
associated with myopia that leads to structural changes in the posterior segment of the eye
(including posterior staphyloma, myopic maculopathy, and high myopia-associated optic
neuropathy) and that can lead to loss of best-corrected visual acuity.1

Presenile cataract is defined as the opacification of the lens and/or its capsule before the age of
40 years when all other known causes of cataract have been ruled out. Cataract is the clouding
of the lens in the eye leading to decrease in vision, primarily a disease of older age groups.
Age-related senile cataract is the commonest eye disorder causing visual impairment and
preventable blindness worldwide, accounting for nearly 48% of all blindness.2
This case study will present more information about pathological myopia and the development
of cataracts, which also includes its prevalence, plan, and management.

KEYWORDS
Pathological Myopia, Posterior Staphyloma, Cataract, and High Myopia

1. https://iovs.arvojournals.org/article.aspx?articleid=2772537
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6618174/#:~:.
INTRODUCTION

Low vision is a term used to describe visual loss that cannot be treated with traditional
eyeglasses, surgery, or medical procedures. Globally, pathologic myopia is a major factor in
reduced vision and blindness. Epidemiological studies have shown its cost in terms of both the
social and economic spheres.

Recent improvements in the myopic maculopathy classification system allow clinicians to

describe a variety of pathologies, including tessellated fundus, diffuse/patchy chorioretinal
atrophy, macular atrophy, lacquer cracks, choroidal neovascularization (CNV), and Fuchs' spot,
all in one format. Myopia has been a widespread health problem around the world, and in the
coming decades, its prevalence is predicted to rise. A refractive mistake known as myopia
causes the picture to focus in front of the retina rather than directly on it. It is believed that both
genetic and environmental variables have a significant impact on how it develops. Pathologic
myopia, sometimes referred to as "myopic macular degeneration," "myopic maculopathy," or
"degenerative myopia," can develop in high myopic eyes and cause a reduction in visual acuity
(VA). In the general community, 1-3% of people have pathologic myopia and one of the leading
causes of blindness and impaired vision all over the world 2. Additionally, pathologic myopia is
viewed as a societal and economic cost because it frequently affects people in their productive
years. Myopia epidemiology research has been carried out all across the world, and the stated
prevalence and its effects on low vision and blindness have varied. Here are some illustrations.
The prevalence of high myopia among young adults is higher in Asian communities
(6.8%-21.6%) than in non-Asian groups (2.0%-2.3%), which is clear evidence of the myopia
epidemic in Asia. Pathologic myopia (PM) or high myopia, which can result in irreversible visual
impairment (VI) 3. Pathologic myopia is more common among middle-aged and elderly people
(0.9%–3.1%) than it is among children and adolescents (0.2%). The advanced lesions found in
elderly persons with PM include lesions such, chorioretinal atrophy, lacquer cracks, Fuchs spot,
and posterior staphyloma (in descending frequency of occurrence) 3. Young adults with severe
myopia were shown to have a reasonably high prevalence of pathologic myopia (8%) in recent
studies. The early grades of PM lesions are likely to evolve to advanced grades as young
people will grow older. The development of chorioretinal atrophy and the enlargement of beta
peripapillary atrophy are two longitudinal alterations that typically occur in pathologic myopia.
The causal conclusions of PM are constrained by the absence of longitudinal changes in
pathologic myopia. Pathologic myopia is ranked as a more important cause of blindness and
low vision in Asian populations compared with Western and European populations 3.
A cataract is a clouding of the eye's lens that impairs vision. Age-related senile cataract, which
is responsible for roughly 48% of all cases of blindness globally, is the most widespread eye
condition that impairs vision and can be treated to prevent blindness.

In both industrialized and developing nations, ladies are more likely than males to have
cataracts. The onset of cataract is earlier in developing nations. Population-based studies have
shown that India has significant incidence rates of cataract when compared to western
populations. Environmental, nutritional, and genetic factors may be important explanatory
factors for these high rates, but there is currently little data on these in the Indian context.
Presenile cataract is defined as opacification of the lens and/or its capsule occurring before the
age of 40, after all other known causes of cataract have been ruled out. This would undoubtedly
increase the burden of age-related cataract in India and throughout the world. The Beaver Dam
Study in Wisconsin found a strong correlation between smoking and cataracts. Inadequate
protein and vitamin intake as well as smoking were linked to cataract in an Australian
population-based cohort research. Brown identified the link between a posterior subcapsular
cataract and vitamin D insufficiency. Rahman noted that risk factors for presenile cataract
included diabetes mellitus, excessive myopia, occupational exposure to metal work, atopic
dermatitis, and smoking. Another study revealed risk elements including steroid usage, alcohol
use, cigarette smoking, and sun exposure.

The good news is that there are various ways to support those who have limited eyesight so
they may carry on with their crucial activities. Losing vision does not need abandoning activities,
but it may require learning new techniques. Losing eyesight does not need abandoning
activities, but it may require learning new techniques.

1https://www.aao.org/eye-health/diseases/low-vision
2https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731360/
3https://pubmed.ncbi.nlm.nih.gov/27898442/
4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6618174/
RELATED LITERATURE

Pathologic myopia (PM) is a major cause of blindness in the world, especially in East Asian
countries. Posterior staphyloma has been considered a hallmark lesion of pathologic myopia.
While axial elongation may primarily start in the equatorial and retro-equatorial region with
secondary changes taking place at the posterior fundus, posterior staphylomas occur in the
posterior segment of the eye and can be associated with, or lead to, vision-threatening
complications in the macula as part of a myopic maculopathy, and myopic optic
neuropathy/glaucoma. 1

Myopia brings further vision challenges because high myopia increases the risk of pathologic
ocular changes such as cataract, glaucoma, retinal detachment, and myopic macular
degeneration, all of which can cause irreversible vision loss. The prevalence of myopia is more
than 2 times higher among East Asians than similarly aged white persons. 2

Cataracts are of particular concern for high myopes for two reasons. Firstly, research shows a
strong association between high myopia and cataracts. In other words, high myopes,
particularly early-onset myopia (before age 20), are at higher risk of developing cataract later on
in life. One possible explanation for this could be that the increasing axial length deprives the
posterior surface of the lens of nutrients, so that it loses its clarity. Other studies suggest that
axial elongation causes damage of the light-receptor cells of the retina, and that a by-product of
this process causes cataract. 3

Presenile cataract is becoming a common occurrence leading to cataract surgery at an earlier

age. Some cases may result from trauma, metabolic, chromosomal, endocrine, and systemic
disorders; yet a sizable percentage is of unknown cause. In this study, we aimed to explore this
disease-caused relationship by studying an association between presence of presenile cataract
with multiple epidemiological, social, and personal agents. Various authors have attributed
different factors in the possible causation of presenile cataract. These included occupation,
social factors like fuel and smoke exposure, personal factors like tobacco and alcohol intake,

vitamin D levels, hypertriglyceridemia, etc.

1 https://link.springer.com/chapter/10.1007/978-981-13-8491-2_9#Sec2
2 https://www.sciencedirect.com/science/article/pii/S0161642016000257
3 https://endmyopia.org/another-problem-with-high-myopia-cataract/
Myopia is etiologically heterogeneous because both environmental and genetic factors play
important roles in myopia development (Morgan et al., 2012). Epidemiological surveys show
that increased outdoor activity plays a pivotal role in myopia progression (He et al., 2015).4
Parental myopia history is significantly associated with the occurrence of myopia, particularly
high myopia, in children (Lam et al., 2008a,b). Myopia heritability has been estimated to be over
90% in large twin studies (Hammond et al., 2001; Lyhne et al., 2001). These studies have
clearly shown the high prevalence of myopia in different populations, especially in East Asian
populations, and this disease has high heritability, indicating the importance and necessity of
studying the genetic landscape of myopia.6

Many studies report a positive correlation between parental myopia and myopia in their children,
indicating a hereditary factor in myopia susceptibility. Children with a family history of myopia
had on average less hyperopia, deeper anterior chambers, and longer vitreous chambers even
before becoming myopic. This implies a strong role for genetics in the initial shape and
subsequent growth of the eye in myopia. Assessing the impact of genetic inheritance on myopic
development may be confounded by children adopting their parents’ behavioral traits, such as
higher-than-average near-work activities. 6

One hypothesis that explains why bright light decreases the risk of myopia development is an
increased release of dopamine, a neurotransmitter found in the retina, that is responsible for
retinal signaling and can influence refractive development. New evidence also implicates diurnal
and circadian rhythms in eye growth and refractive error development.5 Recent studies have
found that spending more time outdoors attenuates the appearance of myopia, however, it does
not slow down its progression. Although the mechanism of action is not yet fully known, several
theories suggest that dopamine is released during exposure to UV light, thereby reducing the
growth of the axial length of the eye. Therefore, the risk of developing myopia is 2.6 times
higher in children with low exposure to sunlight and high near-vision time.4

High myopia can be associated with elongation of the eye and resultant tilting and torsion of the
optic nerve head, causing visual field defects that may resemble glaucomatous damage, but are
the result of myopia.

4 https://www.frontiersin.org/articles/10.3389/fpubh.2020.560378/full
5 https://tvst.arvojournals.org/article.aspx?articleid=2738326
6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1280112/
7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6618174/
CASE SUMMARY

Pathological myopia is a condition that Patient X, a 47-year-old male who resides in Top
Hill, Sudlon, Labangon, Cebu City, as well as his mother, brother, and daughter have. In his right
eye, he also has an acquired senile cataract. He is considered a low vision patient because of
his 20/125 visual acuity. From elementary to high school, he is unable to have vision that isn’t
20/20. When he was a teenager, he was evaluated by an optometrist, given a pair of glasses,
and got a diagnosis of myopia.

During the pandemic time, he went to an optical clinic in Colon, Cebu because of the
gradual changes in his vision. The Optometrist then noted that he had impaired eyesight and
suggested that he visit Dr. Barluado for a checkup. Micheal was given a prescription of OD
-17.00D sph 2.25 cyl @ 45 and OS -16.00D sph 2.25 cyl @ 90.

In proceeding with his examination, we discovered that he has a hard time reading far and near
without his prescription glasses and reading on his left eye area since he has a cataract in his
right eye. Visual acuity was taken using Feinbloom chart results as follows. Unaided vision; OD:
4/40 or 20/200, OS: 4/27 or 20/133, OU: 4/64 or 20/320.

Distance spectacle used at 4 ft. OD: Sph: -17.00D sph 2.25 cyl @ 45 VA: 4/27, OS: -16.00D sph
2.25 cyl @ 90 VA: 4.25 -2, OU: SPH, OD -17.00D sph 2.25 cyl @ 45 and OS -16.00D sph 2.25
cyl @ 90 VA: 4/25 -1.

In visual field test using Amsler Grid at 25cm, OD: can see the center dot, can see the 4
corners, all the lines are straight, can see all the boxes but the lower nasal quadrant is totally
blurred. OS: can see the center dot, can see the 4 corners, all lines are straight, and can see all
the boxes.The patient were barely can see the white dot and the edges

For contrast sensitivity, we used the Felli Robson chart at 40 cm. OD: 33.33 %, OS: 14.84%,
OU: 9.37%. He was able to see some letters but not all. Some faded letters were blurry to him.

For his near vision, without distance spectacles; OD: 1.25m, 10cm, OS: 1.25m, 12cm, OU:
1.25m, 12cm. With own distance spectacles; OD: 1, 16cm, OS: 1, 16cm, OU: 0.75, 16cm. New
distance spectacle; OD: 1m, 16cm, OS: 1m, 16cm, OU: 0.75m, 14cm.

For lighting, he has a photophobia and problems with night vision.

CASE DISCUSSION

A major contributor to blindness worldwide, particularly in East Asian nations, is

pathologic myopia. In the present case as with our patient, he is in the Philippines which
belongs to the East Asian Countries which makes him a candidate for pathological myopia.
Pathological Myopia is defined when there is a complication in the fundus such as posterior
staphyloma, myopic maculopathy, or diffuse choroidal atrophy which is more serious. Our
patient has posterior staphyloma, a condition that can be present in highly myopic individuals
with long axial lengths. According to Sally E (2008), It is caused by elongation of the globe due
to thinning and bulging of the sclera and results in an irregular configuration of the retina at the
posterior pole. Posterior staphyloma should be considered in patients with long axial lengths
and inconsistencies in axial length measures within and between eyes.

The axial length of the eyeball is the distance from the lens to the retina. This will result
in thinning of the retina since it is being stretched thus the Bruch membrane is also affected
since it is located between the retina and the choroid is effect and is responsible for mediating
interactions between the retinal pigment epithelium and blood flow from the choroid (provide
nutrients and oxygen to the outer retina). When this happens nutrient supply in the lens will be
deficient which leads to the development of cataracts.

High myopes should pay special attention to cataracts for two reasons. First, studies
indicate a direct link between severe myopia and cataracts. In other words, high myopes are
more likely to acquire cataracts later in life, especially those with early-onset myopia (before age
20). One explanation for this might be that the posterior surface of the lens becomes less clear
as the axial length increases because it is starved of nutrition. According to other studies, axial
elongation damages the retina's light-receptor cells, and as a result, cataract develops as a side
effect.

Boriwal K (2019) states that myopia changes before cataracts occur, and those over 55
who have myopia changes in their refraction have a very high likelihood of getting nuclear
sclerotic cataracts. The myopic refractive error can move significantly as a result of nuclear
cataracts. This is probably brought on by symmetrical changes in the refractive index within the
lens' nucleus, which result in negative spherical aberration and a myopic shift.

High myopia’s etiology is caused by both genetics and environmental factors. In our
patient, upon taking the Case History he stated that his mother, brother, and daughter have a
similar eye condition and patient M has congenital myopia. Early onset of pathologic myopia
typically has a hereditary basis. And about 90% of studies regarding myopia heritability showed
a high prevalence for children to get the same refractive error from parents. Another cause is
environmental, our Px has previously been working as a call center agent wherein his outdoor
exposure was hindered due to the fact that he is working all night and sleeping all day. He is
now a security night guard, so his sleeping routine is different. His lack of outdoor exposure
added as a factor to the gradual progress of his myopia. According to Translational Vision
Science & Technology (2019), bright light decreases the risk of myopia development is an
increased release of dopamine, a neurotransmitter found in the retina, that is responsible for
retinal signaling and can influence refractive development.

Upon our patient’s visit to Vicente Sotto hospital, doctors found out that he has a scar on
his cornea. We are aware that our patient has a high minus grade and most of the individuals
who have keratoconus also have high minus grade. Myopia and astigmatism brought on by
keratoconus degrade vision and lower the quality of life for those who have it. According to
Aydin K. (2014), One-third of the diagnosed keratoconus cases in the current study had high
myopia but low astigmatism. That is why high myopia alone can be considered as an alarming
sign for further corneal examination to exclude any corneal abnormalities. Corneal thinning is a
common finding in corneas with keratoconus. Rubbing your eyes might weaken the cornea,
which could speed up the progression of keratoconus. According to Atlantic eye Institute (2020)
chronic eye rubbing causes micro-scratches on the cornea, and those small scratches
accumulate to cause serious damage. In the beginning, a scratched cornea may cause
eye-watering, redness, and light sensitivity. If the damage becomes worse, the cornea can
become infected or develop scar tissue.

In regards to our patient’s eccentric viewing in the upper nasal quadrant, it’s because his
high myopia can induce the eye to enlarge, which causes the optic nerve head to tilt and twist.
This can result in visual field anomalies that may resemble glaucoma damage but are basically
caused by myopia. His lower contrast sensitivity in the right eye is due to cataracts and miosis.
Cataract since lesser light enters the eye and the stimulus of light is a vital factor to have a good
contrast viewing. And meiosis since our patient is a younger adult.
Management and Recommendation

Patient M with presenile cataract and pathologic myopia has a hard time to see details
even with his glasses and experienced difficulty in reading and other activities of daily living. The
progression of presenile cataracts is usually slow, but presenile cataract and pathologic myopia
can eventually cause significant vision loss. It can be a long process and the treatment will
depend on the severity as well as the patient’s medical history. There is currently no cure for
pathologic myopia but treatments may help improve vision.

The most effective treatment for Patient M is to undergo cataract surgery that involves
removing the clouded lens and replacing it with a clear artificial lens. This is a relatively safe
procedure that can be done on an outpatient basis. To free him from the cloudiness of his vision.

There is also non-surgical treatment which is the refractive correction and it involves
using glasses to correct vision problems caused by the presenile cataract and pathologic
myopia and also the patient can use contact lens to widen the patient's field of view and to
avoid trips and bumps at night. However, this method of treatment only offers temporary relief
from its symptoms.

Patient M was recommended to wear sunglasses to reduce glare and protect the eye
from too much exposure to UV rays that predisposes to cataract. The patient is a night shift
security guard so as clinician we advised Patient M to wear yellow clip-on glasses to block night
time glare and everything will look brighter and clearer at night.

We also advised the patient to use strong color contrast especially in his surroundings
since his house leads to a lot of stairs, also good room illumination for him to have good
mobility. It is highly recommended for the patient to have regular check up to his Optometrist
and Ophthalmologist for eye health and vision monitoring.
DOCUMENTATION
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Brown, N. A., & Hill, A. R. (1987). Cataract: the relation between myopia and cataract
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