Detecting peripheral retinal lesions in children with myopia

Axial myopia is the most common form of myopia, caused by an increase in the axial length (AL) of the eyeball.¹ As such, myopia is not simply about prescribing glasses but is associated with several ocular complications, such as retinal detachment (RD), macular atrophy and glaucoma, rising exponentially beyond –6.00 D. These complications are mainly related to the tissue stretching and histological damage that accompany the elongation of the eyeball.

Severely myopic eyes show up to an 800-fold increase in the risk of myopic macular degeneration and a 13-fold increase in the risk of RD compared with non-myopic eyes. For individuals with an axial length of 30 mm or more, the probability of severe visual impairment by age 75 approaches 90%.² In children, non-traumatic rhegmatogenous retinal detachment (RRD) is particularly worrisome: if not identified and treated promptly, it may occur in both eyes and result in permanent vision loss.³

High axial elongation may give rise to peripheral retinal lesions such as white-without-pressure (WWP), dark-without-pressure (DWP) and microcystoid degeneration. These entities are generally regarded as benign, with a low risk of RRD and, therefore, in most cases, periodic monitoring at 1- to 2-year intervals is recommended.⁴

Our aim was to determine whether the severity of myopia is linked not only to the presence of peripheral retinal lesions but also to the specific types of these lesions. These lesions are more challenging to detect in routine practice because the retinal periphery is less accessible with traditional examination methods and conventional fundus imaging. Because most of the existing evidence on peripheral lesions concerns adults, we sought to address this gap by examining how often these lesions occur in children with high myopia and whether they are associated with changes in biometric parameters.^5-9 To maximize visualization of the far periphery, we primarily used ultra-widefield imaging (California; Optos), which provides a single-shot 200° view—the widest field of view currently available in a single capture.¹⁰ The results of our study were recently published in the British Journal of Ophthalmology.¹¹

The critical role of myopia in paediatric retinal risk

Out of a total of 160 eyes, 32 were in the 4- to 6-year age group and 128 were in the 7- to 17-year age group, with the latter group showing a higher minus spherical refractive error.

Peripheral retinal lesions were frequent: 54.4% of all examined eyes had at least one lesion. Among eyes with lesions, 57% had a single lesion and 43% had multiple lesions. Lesions were bilateral in most children (64.2%). Retinal lesions were significantly more common in the older age group, which also showed a higher prevalence of multiple lesions than the younger group.

DWP was the most frequent lesion in both age groups. By contrast, younger children rarely displayed WWP, snail-track, microcystoid degeneration or lattice degeneration. In this younger group, the second most frequent category consisted of unclassified peripheral anomalies that did not fit current clinical definitions (Figure).

Interpreting the evidence: Biometric predictors and clinical impact

In the scientific literature, other studies have addressed peripheral retinal findings in children below age 10,^6,9 or included older participants (19-25 years⁵ and 10-40 years⁸). However, to the best of our knowledge, this study represents the largest analysis focused exclusively on a paediatric population (4- to 17-year-olds) with high myopia (mean spherical equivalent, –9.95 ± 3.59 D).

Our findings align with those of earlier paediatric and young adult studies that report similar rates and patterns of peripheral lesions in eyes with high myopia. The comparable lesion burden observed across children, young adults and older adults with severe myopia confirms that once axial length surpasses a certain threshold, it becomes a key driver of peripheral retinal change: in our study, every 1-mm increase in AL was strongly associated with a higher likelihood of both lesion presence and multiplicity.

Axial length as a clinical threshold

Most importantly, our analysis found actionable clinical thresholds for proactive intervention with AL as the single most critical measurement: the probability of a child developing any peripheral retinal lesion reaches 50% at 26.2-mm AL with a refractive error of –8.6 D, and the risk increases to 80% at 29.4-mm AL with a refractive error of –17.8 D. Critically, the threat of developing multiple lesions in the retina, a sign of increased structural fragility, reaches the 50% probability at 28.6-mm AL and –14.9 D refractive error. These specific values can serve as benchmarks for triggering intensive, systematic peripheral retinal evaluation in this population.

A review of the wider literature reinforces this interpretation. As myopia progresses over the years, peripheral retinal lesions are found in around 60% of adult eyes with mild or moderate myopia—figures that are similar to our data—but this prevalence rises to over 84% in high myopia.¹² In addition, older age, increased AL and higher degrees of myopia have been identified as statistically significant predictors of peripheral retinal degeneration.¹³

Implications for surveillance

Taken together, these observations underline a clear risk: continued myopic progression increases the probability of developing peripheral lesions. DWP and WWP are usually regarded as benign and not an immediate cause for intervention; however, our findings suggest that they may be markers of peripheral retinal remodelling in eyes with high myopia, rather than isolated incidental findings. In the context of progressive high myopia, such changes can predispose patients to more serious situations, including retinal holes, breaks or tears, and, ultimately, increase the risk of RRD.⁴ This has practical implications for follow-up: both age and degree of myopia should guide surveillance strategies, with closer monitoring of peripheral lesions in children, where axial elongation and myopic progression are most rapid.

In our cohort, DWP was the most frequent peripheral lesion, followed by WWP, which was seen predominantly in older children. Classical degenerations such as lattice and snail-track were uncommon in the youngest children but became more prevalent with increasing age. This pattern supports the concept that these lesions develop progressively as cumulative mechanical stress and peripheral thinning increase with axial elongation. Lesions were also more frequently located temporally,¹⁴ consistent with known regions of greater peripheral stress in eyes with myopia.

The fourth most common lesion in our study, microcystoid degeneration, is also considered harmless and age related, though its cause is not fully understood. However, one study concluded that cystoid degeneration was present in more than half of participants with RRD, near the retinal breaks or areas of detached retina,¹⁵ which suggests it might signal a region of structural fragility, even if it does not directly cause RRD. Beyond this hypothesis, lattice and snail-track degeneration are already known as definite RRD precursors.^16-19 Their presence in children calls for careful long-term surveillance and an individualized, risk-adapted follow-up strategy.

The role of imaging

In conclusion, peripheral retinal lesions are common in children with high myopia. Their prevalence, severity and bilateral occurrence increase with age and AL, with AL being the strongest and most consistent predictor. Early lesions such as DWP and WWP may signal peripheral retinal stress and may interfere with modern myopia-control approaches.

Ultra-widefield imaging plays a crucial role in detecting these peripheral lesions, offering particular advantages in paediatric populations: the single-capture, non-contact imaging process is well tolerated by children, and the 200° field of view remains effective even in eyes with longer AL, where conventional examination methods may be more challenging. These findings support early and thorough peripheral retinal assessment in children with high myopia and underline the need for further studies to clarify the long-term impact of these lesions.

Jacques Bijon, MD

E: [email protected]

Jacques Bijon, MD, is a vitreoretinal fellow at the French Institute of Myopia at Adolphe de Rothschild Foundation Hospital in Paris, France. He trained in ophthalmology in Lausanne, Switzerland, and Paris and completed a medical retina research fellowship in New York, USA.

Thibaut Chapron, MD, PhD

E: [email protected]

Thibaut Chapron, MD, PhD, is affiliated with the French Institute of Myopia at Adolphe de Rothschild Foundation Hospital in Paris, France. He is also associated with Université Paris Cité, CRESS (Centre de Recherche en Épidémiologie et Statistiques), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, Paris, France.

Neither Dr. Bijon nor Dr. Chapron has any financial disclosures to declare.

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