High myopia is a condition that occurs in eyes that are myopic (shortsighted), in which the spectacle power is -6.00 D or more. Complications of high myopia are related to structural changes of the eyeball. In patients with high myopia, there is an excessive elongation of the eyeball. Some may progress to outpouching (“staphyloma”) of the eye wall at the back (Figure 1). The risks of sight threatening eye diseases increase exponentially with an increase in spectacle power.
Figure 1: Staphyloma is a localized bulge of back wall of the eyeball (blue arrows).
Structural changes in myopia may lead to thinning of the retina (innermost nerve sensitive tissue of the eye). Due to this change, a hole or break more easily develops in the retina (Figure 2). This allows fluid from the center of the eye called the vitreous, to seep in between the two layers of the retina (the light-sensitive cell layer and the outer pigmented layer). This causes these two layers to separate from each other. The higher the spectacle power, the higher the risk of RD. Possible symptoms of RD include floaters (black or red moving dots in your vision), flashing lights and loss of vision, usually starting with a “curtain-like” area of blurring in the vision. This condition is considered an emergency, and urgent surgical treatment is needed to prevent irreversible loss of vision.
Figure 2: View of the back of the eye showing detachment of the retina from 8 o’clock to 1 o’clock in the picture in an eye with typical myopic features
Cataract is a clouding of the natural lens of the eye that leads to a decrease in vision, usually in a painless and gradual manner (Figure).Cataract is the leading cause of blindness worldwide and it is a condition that occurs naturally with age. Several studies found that cataract may develop earlier in myopic eyes. Early symptoms of cataract include increasing myopic lens power requirement, blurring of vision despite spectacles, and glare at night as well as decrease in night vision. Cataracts can be treated very effectively with surgery that usually restores vision.
Figure 3: Dense white cataract
Patients with pathological myopia may have thinning of the retinal layers in the central part of the retina. This central area of the retina is called the macula, which is responsible for fine, central vision. The long eyeball in highly myopic eyes can develop cracks in its layers causing retinal degeneration. Damage to the macula affects the central vision, which is important for tasks such as reading, writing, driving and recognizing people’s faces and etc. Treatment may be possible when new blood vessels occur in the form of eye injections.
Figure 5A: Retina in a eye with myopic macular degeneration and Figure 5B: Normal looking retina. The pictures highlight the different appearance of MMD eyes compared to normal. This is due to marked degenerative changes that occur in the retina of highly myopic eyes.
Myopic traction maculopathy (MTM), also known as “myopic foveoschisis” occurs due to stretching and splitting of the retinal layers at the macula. As the eyeball elongates in myopia, the layers of the retina are unable to follow the elasticity of the eye wall’s contour. The central macula may also detach (“foveal detachment”) and can develop a hole at its centre (“myopic macula hole”). MTM requires regular monitoring as it may worsen even when vision is still good. Optical coherence tomography (OCT) is a non-invasive investigation available in most eye specialist clinics, that uses light energy to generate a 2 and 3D image of the macula and optic nerve. OCT of the macula allows MTM in its various stages to be diagnosed by the eye specialist. Treatment should be given before worsening of vision and increased distortion (seeing straight objects as wavy or crooked). MTM may be treated with surgery with variable outcome.
Figure 6: OCT in a patient without myopia showing normal appearance of the macula centre, an area called the fovea.
Figure 7: OCT in patient with myopic foveoschisis showing stretching of the retina layers at the macula due to elongation of the eyeball
Glaucoma is a group of eye conditions that damage the optic nerve. It is one of the leading causes of irreversible blindness for people over the age of 60. It is also known as the ‘silent thief of sight’ as it has no or mild symptoms until later stages of the disease in the “open-angle” type. Mild symptoms are usually not specific, such as headache or blurred vision in one eye. The risk of “open-angle” glaucoma is higher in persons with myopia. Furthermore, the detection of glaucoma is more difficult due to structural changes of myopia itself. Nevertheless, early detection is crucial because damage to the optic nerve is often permanent and irreversible. Hence, the aim of glaucoma treatment is to preserve remaining eyesight and prevent further loss. Treatment includes life-long eyedrop therapy, laser and when needed, surgery.
Figure 9: This picture shows the result of a test called a visual field test done on one eye of a patient with glaucoma of moderate severity. The visual field is the area you can see with your eye. The dark areas in this field are areas which the patient is unable to see. The light areas are where vision is still intact.
Figure 10: Visual field picture showing severe glaucoma which gives the patient a “tunnel” kind of vision; namely only in the centre of the field. Treatment should be given before vision is lost to this level.
Myopia is one of the commonest reasons for persons to wear contact lenses as it gives them freedom from their glasses and what some individuals perceive as better appearance. However, contact lens wear comes with responsibility. One of the indirect consequences of myopia include the development of ulceration of the cornea in persons with poor contact lens hygiene (Figure 11). The cornea is the clear, transparent tissue located at the front of the eye, in front of the iris which gives our eyes their colour. Cornea ulceration is a serious and potentially blinding condition that requires urgent treatment to save the eyesight. Early symptoms include eye discomfort, a sensation of dust in the eye and tearing. Mild infection can be treated with antibiotics. Later symptoms include pain, red eye, poor vision and yellowish discharge from the eye. Severe cornea infection can lead to blindness due to a scar developing in the cornea. If the scar is in the centre of the cornea, transplantation of a donor cornea to restore vision may be needed (Figure 12). Good hygiene and avoidance of overwear while using contact lenses is one of the most important factors in preventing infection.
Figure 11: Ulceration of the cornea in a contact lens user can be seen as a whitish discolouration of the central part of the eye, in an eye that also looks red.
Figure 12: Picture showing the appearance of an eye that has undergone a transplant of new cornea from a donor to restore clear vision. The black lines radiating outwards represent fine stitches to keep the new cornea in place.
Worldwide there are almost 1.5 billion people living with myopia and 163 million with high myopia. Even though myopia in most cases can be easily corrected with glasses, contact lenses or surgery, the large and increasing numbers of persons with myopia also mean eye specialists (ophthalmologists) are encountering more complications from myopia. It has been estimated that as many as 10 million people worldwide have vision loss from myopic macular degeneration (MMD) and 3.3 million are legally blind. This number could rise to 55 million people with impaired vision and 18.5 million blind by 2050, or 0.57% and 0.19% of the world’s population respectively.2
Persons with high myopia (power of -6.00D or more) should consider having their eyes screened by an ophthalmologist for the complications mentioned above, even if they experience no symptoms. It is especially important to be aware of the complications of myopia and seek treatment as soon as symptoms occur.
Acknowledgments: Eye images from the Imagenet, Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia
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DR. Safinaz Mohd Khialdin (Paediatric Ophthalmologist, PPUKM)
DR. Safinaz Mohd Khialdin is a medical lecturer, researcher, and a consultant paediatric ophthalmologist at Universiti Kebangsaan Malaysia (UKM). She is the chairperson of the Malaysian Advocacy for Myopia Prevention (MAMP). Safinaz obtained her Masters in Ophthalmology in 2010 from UKM. She then completed her fellowship training in Paediatric Ophthalmology in 2014 at Westmead, Australia. She has conducted over 25 research projects and has published over 45 peer reviewed publications. Her main research interest is in paediatric ophthalmology, mainly on myopia. She has been invited to give lectures in scientific conferences and in public talks. Safinaz is also the committee in the postgraduate ophthalmology training programme in Malaysia.
PROF DR. Mae-Lynn Catherine Bastion (Vitreoretinal surgeon, PPUKM)
Professor DR. Mae-Lynn Catherine Bastion MBBS (Syd) (Honours Class 1) FRCSG (UK) DrOphth (UKM) FAMM (Mal) is a senior consultant ophthalmologist at Universiti Kebangsaan Malaysia (UKM) and UKM Specialist Centre. She obtained her fellowship in Vitreoretinal Diseases and Surgery at The Eye Institute @ Tan Tock Seng Hospital, Singapore. She has an interest in childhood myopia prevention and surgical treatment for posterior complications of myopia. She was appointed UKM Professor of Ophthalmology (Vitreoretina) in 2014 and received the Best Senior Clinical Teacher Award from Faculty of Medicine in 2019. She is a member of the Malaysian Universities Conjoint Committee of Ophthalmology, and treasurer of the Malaysian Society of Ophthalmology. She has on-going research grants and over 70 peer-reviewed publications. She finely balances her work life with a busy family life.
DR. Choong Yee Fong (Paediatric ophthalmologist, ISEC KL)
DR. Choong Yee Fong is the medical director of International Specialist Eye Centre (ISEC), Kuala Lumpur and a consultant ophthalmic surgeon with sub specialty interest in refractive cataract surgery, paediatric ophthalmology and strabismus. He was an ASEAN Scholar and a recipient of the prestigious British High Commissioner’s Award to study Medicine in the United Kingdom. He graduated with Bachelor of Medicine and Surgery (MBChB) from the University of Leeds with numerous academic awards including the prestigious University Crabtree Award. He was conferred Fellow of the Royal College of Ophthalmologists (FRCOphth), London and was awarded the Certificate of Completion of Specialist Training (CCST) upon completion of the higher specialist training in the U.K. He is also a founding member and a member of the scientific bureau of the World Society of Paediatric Ophthalmology and Strabismus since 2008.
DR. Sunder Ramasamy (Paediatric ophthalmologist, Thomson Hospital & OasisEye)
DR. Sunder Ramasamy is a consultant ophthalmologist and paediatric ophthalmologist at Thomson Hospital Kota Damansara and Oasis Eye Specialist. He is also a visiting consultant ophthalmologist with the Ministry of Health Malaysia. Dr. Sunder has extensive exposure in the field of ophthalmology. In addition, he is also subspecialty trained in the field of Paediatric Ophthalmology at the Singapore National Eye Centre and is Exit Certified by the Ministry of Health Malaysia. Dr. Sunder’s focus of interest is in children related eye conditions like myopia, strabismus, amblyopia, paediatric cataracts and paediatric glaucoma. Dr. Sunder is a fellow of the International Council of Ophthalmology and a member of the Malaysian Society of Ophthalmology.
MS. Tang Shin Ying (Optometrist, ISEC KL)
MS. Tang Shin Ying is a qualified optometrist and the head of the department of optometry at International Specialist Eye Centre (ISEC) Kuala Lumpur. She is also a member of the Association of Malaysian Optometry (AMO). She graduated from International University College of Technology Twintech (IUCTT). She completed her Clinical Internship in Optometry at Sankara Nethraya Eye hospital (SNEC) in India and several government hospitals in Malaysia. She obtained her Master in Business Administration (MBA) with first class honour at INTI University. Ms Shin Ying has been actively involved in the clinical audit research and was invited as a speaker at the ATIOL symposium, Kuala Lumpur, 2020, presenting clinical audit of cataract surgical outcome. She has special interest in paediatric optometry and myopia control in children.
DR. Duratul Ain Hussin (Optometrist, HKL)
DR. Duratul currently is a Senior Principal Assistant Director of the Allied Health Sciences Division, the Ministry of Health (MOH) Malaysia. She is an Optometrist by profession, with experience working at various public hospitals throughout Malaysia since graduated from the National University of Malaysia in 2000. Duratul’s PhD research at QUT Australia was on the development and evaluation of primary eye care pathway effectiveness at a health clinic in Malaysia. In addition to her main role within the Ministry, Duratul continues to work on a special project for the expansion of Optometry care services into public community health clinics in Malaysia, which includes strategic partnership with the private sector. She is also coordinating preschool vision screening program and cerebral visual impairment service in the MOH Malaysia since 2017.
DR. Miswan Muiz Mahyuddin (Cataract & Refractive Surgeon, Tun Hussein Onn National Eye Hospital)
DR. Muiz is the current Vice-President of the Malaysian Society of Ophthalmology and Consultant Ophthalmologist and Refractive Surgeon at the Tun Hussein Onn National Eye Hospital. He graduated a scholar in 2001 from the University of Otago in New Zealand. He completed his Masters of Ophthalmology from University Malaya in 2010. Dr Muiz was a Lecturer in UiTM Medical Faculty and has experienced working in HUKM, HKL, UMMC and HATTM. His main interest is in correcting refractive errors and presbyopia through the use of LASIK, ReLEx SMILE and refractive intraocular lenses. He also manages children with myopia and orthokeratology in his practice.
PROF DR. Choo May May (Paediatric ophthalmologist, PPUM)
PROF DR. Choo May May is a professor at University of Malaya, Kuala Lumpur. She qualified as an ophthalmologist in 1999. Her subspecialty training includes Paediatric Ophthalmology at Royal Alexandra Children’s Hospital (2003) and at Westmead Hospital (2014) for glaucoma surgery in complex cases.
She initiated University of Malaya’s collaboration with University of Sydney on completion of training and organised 2 seminars at the APAO conferences in Beijing and Sydney. She has lectured at Malaysian Paediatric Association and Perinatal Society of Malaysia conferences. Currently she is in the committee to spearhead activities of MSO’s Myopia project for World Sight Day 2021.
DR. Azlindarita @ Aisyah Mohd Abdullah (Paediatric ophthalmologist, MSU Medical Centre)
DR. Aisyah is a General and Paediatric Ophthalmology Consultant in MSU Medical Centre Shah Alam and sub-speciality interest in Paediatric Ophthalmology and Strabismus. She graduated with Bachelor of Medicine (MB CHB BAO) from the National University of Ireland, Galway in Year 2004. She obtained her Masters of Ophthalmology at University Malaya, and sub-speciality training at University Malaya Medical Centre (UMMC). She completed her internship at Ballinasloe Hospital & University College Hospital Galway in Ireland. She is also a member of International Paediatric Ophthalmology and Strabismus Council (IPOSC). Dr Aisyah formally worked as a Medical and General Surgical Officer at Selayang Hospital, and Medical Lecturer and Specialist at UiTM. She has special interest in strabismus in adults and children and myopia control in children in the time of pandemic. She is married to a GP, with 4 kids.
DR. Norazah Abdul Rahman (Paediatric ophthalmologist, SJMC Subang Jaya)
DR. Norazah is a board certified ophthalmologist specializing in Paediatric Ophthalmology and Strabismus in Ara Damansara Medical Centre. She holds a Fellowship of Paediatric Ophthalmology and Strabismus conferred by the Ministry of Health Malaysia. She graduated with Bachelor of Medicine and Surgery (MBBS) from University of Malaya. She obtained her Master of Ophthalmology from the same university. She is also a member of the Malaysian Society of Ophthalmology (MSO) and the World Society of Paediatric Ophthalmology and Strabismus (WSPOS). Dr. Norazah offers her time and expertise to service agencies in her community as well as national organizations including Cataract camp and public eye screening. Her main passion is in assisting children restore vision through diagnosis and treatment of eye disorders such as squint eye, myopia, lazy eye, ocular allergies, and paediatrics glaucoma and paediatrics cataracts. She is also active in doing volunteer work for the underprivileged children and adults alike.
DR. Malisa Ami (Paediatric ophthalmologist, Sunway Specialist Centre Damansara)
DR. Malisa is a consultant ophthalmologist at Sunway Specialist Centre Damansara with subspecialty interest in paediatric ophthalmology, strabismus and laser vision correction. She graduated with distinctions from the Queen’s University of Belfast, United Kingdom, and was awarded the Phase 2 Foundation Scholarship. After gaining exposure to ophthalmology at the Royal Victoria Hospital Belfast, she returned to Malaysia and obtained the Doctor of Ophthalmology from the Universiti Kebangsaan Malaysia. She then completed a Fellowship in Paediatric Ophthalmology & Strabismus at the University of Auckland, New Zealand. She had served as a lecturer in ophthalmology at UKM and was awarded Excellence in Service Award in 2015. She also has authored several scientific papers in both national and international ophthalmology journals.
DR. Fazilawati (Paediatric Ophthalmologist, Hospital Klang)
DR. Fazilawati is Head of Department Ophthalmology, Consultant Ophthalmologist and Paediatric Ophthalmologist from Hospital Tengku Ampuan Rahimah, Klang. She joined University Malaya to pursue Masters training in Ophthalmology. After obtaining her Masters Degree, she then went on to do a 1 year Fellowship training in Paediatric Ophthalmology at the prestigious Hospital for Sick Children, University of Toronto, Canada. Upon returning to Malaysia, she was posted to Hospital Selayang where she held the position as Head of Unit in Paediatric Ophthalmology & Strabismus Services for 5 years before joining Hospital Tengku Ampuan Rahimah, Klang as the head till present. Dr Fazilawati is a member of the Council of Ophthalmology Academy of Medicine Malaysia; an international member of the American Academy of Paediatric Ophthalmology & Strabismus, World Society of Paediatric Ophthalmology & Strabismus and the International Paediatric Ophthalmology and Strabismus Council.
