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蕭閔謙醫師 · 眼科衛教筆記
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📑 8-year prospective cohort · Jiang et al. 2026 · Am J Ophthalmol · Zhongshan · 310 eyes
Latest Research · High Myopia · Maculopathy

Childhood High Myopia: In 8 Years
1-in-3 Develop Maculopathy

A 2026 prospective cohort study in American Journal of Ophthalmology by Jiang, Wang et al. at Zhongshan Ophthalmic Center followed 155 highly myopic children/adolescents (7–17 y, spherical equivalent SE ≤ −6.0 D), 310 eyes, examined every 2 years for 8 years. Key findings: 31.3% (97/310) of eyes showed myopic maculopathy (MM) progression over 8 years, most commonly a newly appearing tessellated fundus (44.6%). Crucially, adding the «2-year axial-length change rate» to a baseline model raised the accuracy of predicting 8-year MM progression from AUC 0.772 (baseline AL only) to 0.829, with an optimal cut-off of 0.325 mm/year. Pathologic myopia (PM) was itself a strong predictor (~6× risk). In plain terms: the faster a highly myopic child's eye elongates in the first two years, the higher the future maculopathy risk — giving us a chance to identify high-risk children early and intervene sooner.

⚠️ Disclaimer: General medical education, summarising a 2026 prospective cohort study (Jiang F, Wang L et al.) in Am J Ophthalmol. This article does not replace individual evaluation by your treating ophthalmologist; myopia control and high-myopia surveillance must be individualised by your eye doctor. The study was conducted at a single centre in Guangzhou, China, in a predominantly Han-Chinese paediatric population — similar to but still requiring cautious extrapolation to Taiwanese children. This site does not engage in medical advertising or endorse any specific drug, clinic, or physician. For coverage and costs of myopia-control treatments (e.g. low-dose atropine, orthokeratology, red-light therapy) and examinations, refer to your hospital's pre-service notice and the latest NHIA announcements.
高度近視兒童黃斑部病變一張圖看懂：眼軸拉長病程 + 預測模型 + 行動卡 Diagram: axial elongation and the Meta-PM C0–C4 maculopathy progression scale, a prediction-model comparison (baseline AUC 0.772 vs adding the 2-year axial-length change rate AUC 0.829 with a 0.325 mm/year cut-off), and three patient-action cards. Childhood High Myopia: Axial Length → Maculopathy Jiang et al. 2026 · Zhongshan · 310 eyes · 8-year follow-up ① Axial elongation → 5-stage maculopathy (Meta-PM) Longer axis → posterior pole thins (choroid thins, sclera remodels) C0 正常 C1 豹紋狀 C2 瀰漫萎縮 C3 斑塊萎縮 C4 黃斑萎縮 → 越右越嚴重 → + «plus» lesions: lacquer cracks, Fuchs spot, CNV 31.3% of eyes moved right (progressed) in 8 years Those with atrophy nearly all progress: C2 77%, C3 100% ② Adding the «2-year AL change rate» predicts better AUC closer to 1.0 = better prediction of 8-yr progression Baseline AL only AUC 0.772 Baseline AL + 2-yr AL change rate AUC 0.829 ↑ P=.013 ⚑ High-risk cut-off: axial length growing ≥ 0.325 mm/year Children above this speed face notably higher future progression risk Pathologic myopia itself ~6× risk (OR 6.26) ✱ Short-term (2-yr) axial change = early signal of long-term (8-yr) progression ✓ Track axial length High-myopia children Track axial-length trend AL change beats refraction as an objective progression marker (with dilated fundus exam) ! High-risk features AL ≥ 0.325 mm/year Younger, very high SE Already pathologic myopia These children need more aggressive control + follow-up ⚠ Read with care Single centre, Han-Chinese Model not externally validated Cut-off is a research value Risk + control decisions individualised by your doctor High-myopia kids: fast axial growth in first 2 years → early warning for future maculopathy
Pediatric high-myopia maculopathy at a glance. ① As axial length increases, the posterior retina thins, the choroid thins, and the sclera remodels; myopic maculopathy is graded by the Meta-PM system from mild to severe: C0 normal → C1 tessellated fundus → C2 diffuse chorioretinal atrophy → C3 patchy atrophy → C4 macular atrophy, plus «plus» lesions (lacquer cracks, Fuchs spot, CNV). Over 8 years, 31.3% of eyes moved to a more severe stage; eyes with existing atrophy (C2, C3) almost all progressed. ② Prediction model: baseline AL alone predicted 8-year progression at AUC 0.772; adding the first 2-year AL change rate raised it to 0.829 (P=.013), with a high-risk cut-off of ≥0.325 mm/year; pathologic myopia itself carried ~6× risk. ③ Three take-homes: (green) high-myopia children should have regular axial-length measurement plus dilated fundus exams; (yellow) high-risk features = fast axial growth, younger age, very high myopia, existing pathologic myopia; (red) this is a single-centre Han-Chinese study, the model is not externally validated, and the cut-off is a research value not a personal diagnostic line — risk and control decisions should be individualised by your ophthalmologist. Source: Jiang et al. 2026 AJO (Zhongshan, 155 patients / 310 eyes, 8-year follow-up).

1. Common clinic scenarios

'Doctor, my child is already over −7 D in primary school; the prescription keeps climbing and the axial length keeps growing. I know myopia control matters, but what I really worry about is — will his eyes eventually «break down»? Could he go blind like the news says?'

'Doctor, every visit you measure an «axial length» number for my child — what's it for? How is it different from the prescription? What can it tell us?'

'Doctor, I'm highly myopic too and my fundus photo shows «tessellation». Is this hereditary? My child seems fine now — does that mean we don't need to worry?'

All these point to the same thing: what high-myopia families fear most isn't «how many diopters» but whether the eye will reach irreversible maculopathy. The 2026 Zhongshan 8-year follow-up study answered two key questions for the first time: (1) what fraction of high-myopia children's maculae progress over 8 years? (2) can short-term axial-length change predict who will progress? This article translates it into clinic language.

2. Common patient Q&As

Q1: How likely is maculopathy progression in 8 years for high-myopia children?
A: In this study, about 1 in 3 (31.3%). Among 310 high-myopia (≤ −6 D) children's eyes followed for 8 years, 97 showed maculopathy progression. The commonest change was a newly appearing tessellated fundus (44.6% of all changes) — the earliest sign of myopic maculopathy, reflecting choroidal thinning that lets the underlying vessels show through. This reminds us high myopia isn't just «blurry vision needing thicker glasses» — structural fundus changes genuinely accumulate from childhood into early adulthood. To be clear, though: progression in 8 years does NOT equal blindness — most were early changes (normal → tessellated); few reached severe atrophy.
Q2: Why measure «axial length»? How is it different from the prescription?
A: Axial length is the eye's actual front-to-back length — a more stable, objective progression marker than refraction. Refraction (spherical equivalent) is affected by the cornea, lens accommodation, and the moment of testing; axial length (measured directly by optical biometry) reflects how much the eye has truly elongated. This study's key finding: adding the first 2-year axial-length change rate raised the accuracy (AUC) of predicting 8-year maculopathy progression from 0.772 to 0.829 — meaning how fast the eye elongates itself carries predictive information about future complications, not just a basis for new glasses. That's why more eye clinics now treat regular axial-length measurement as standard surveillance for high-myopia children.
Q3: What does the «0.325 mm/year» cut-off mean? Does exceeding it guarantee trouble?
A: It's a statistically derived reference line to separate high vs low risk — not a diagnostic «cross it and you go blind» threshold. The researchers used Youden's index to find the axial-growth speed that best distinguished «will progress vs won't»: about 0.325 mm/year. Read it as: children whose eyes grow faster than this in the first 2 years are, on average, a group needing closer attention. But three caveats: (1) it's a population-level risk boundary, not a personal guarantee; (2) it comes from a single-centre, specific population; Taiwanese children may differ; (3) it's a tool to identify who should be controlled more aggressively, not a number to scare yourself or self-diagnose with. Whether you are truly high-risk and whether to adjust treatment is for your ophthalmologist to judge holistically.
Q4: Which children are most at risk? Are there «high-risk features»?
A: The study highlights several high-risk features. (1) Fast axial growth: high 2-year AL change rate (≥0.325 mm/yr). (2) High myopia at a younger age: progressors were actually younger on average (12.9 vs 14.0 y) — earlier high myopia means more remaining growth years for the eye to keep elongating. (3) Deeper refraction, longer axis: progressors had deeper baseline SE (−10.7 vs −8.5 D) and longer AL (27.7 vs 26.7 mm). (4) Already pathologic myopia (PM): ~6× higher progression risk. (5) Already has lacquer cracks: these children were younger, extremely myopic (mean −13.7 D), and elongated faster. The more features present, the greater the need for aggressive control and intensive follow-up.
Q5: So how do I «control» it? Did this study say which method is best?
A: This is a «prediction» study, not a «treatment comparison» — it did not compare which control method is best. In fact, to cleanly observe natural progression, the study deliberately EXCLUDED children using orthokeratology, low-dose atropine, or repeated low-level red-light therapy. So its message is «who is high-risk and needs close watching», not «which drug to use». Myopia-control tools (low-dose atropine, ortho-K, special optical-design lenses, outdoor time) each have their own evidence and indications, chosen by the ophthalmologist based on the child's age, refraction, axial-progression speed, and adherence. Read alongside myopia-control articles, the logic is: use axial length to flag high risk → then the doctor selects the appropriate control method.
Q6: Isn't maculopathy an «old people's» disease? How can a child have it?
A: «Myopic maculopathy» differs from age-related macular degeneration (AMD) — its root cause is axial elongation, and it can begin in childhood. Myopic maculopathy does mostly manifest after 40, but research shows its pathological changes often quietly begin in childhood and adolescence, during rapid ocular growth. A 20-year study found children with specific choroidal atrophy were more likely to develop maculopathy in adulthood. In this study, children who developed lacquer cracks were on average only ~20 years old at the 8-year visit. So the point is: a high-myopia child's fundus shouldn't be taken lightly just because «vision is still okay now» — structural changes may already be accumulating.
Q7: How often should high-myopia children be checked, and with what tests?
A: Frequency and tests are set by the ophthalmologist based on individual risk, but this study highlights two key examinations. The study did a full assessment every 2 years, including: (1) axial length (optical biometry) — to track elongation speed; (2) dilated macula and optic-disc fundus photography — to grade progression by Meta-PM; plus corrected acuity, IOP, and refraction. In practice, for high myopia or fast axial progression the doctor may shorten the interval (e.g. every 6–12 months) and add OCT as needed. Key message: a high-myopia child's visit shouldn't be just «check the prescription and change glasses» — it should include axial length and a dilated fundus exam to catch early macular changes.

3. 30-second takeaway: 8 things to remember

📋 Pediatric high-myopia maculopathy: 8 things to remember

  • 1-in-3 progress in 8 years: 155 high-myopia children, 310 eyes, 31.3% maculopathy progression over 8 years (Zhongshan cohort)
  • Commonest = new tessellated fundus (44.6%) — earliest maculopathy sign, reflecting choroidal thinning
  • 2-year AL change predicts 8-year progression: AUC 0.772 → 0.829 when added (P=.013)
  • High-risk cut-off: AL ≥0.325 mm/year — a population boundary, not a personal diagnosis
  • Axial length is more objective than refraction: reflects true elongation; standard surveillance for high-myopia children
  • High-risk features: fast axial growth, young-onset high myopia, very deep SE, existing pathologic myopia (~6× risk), lacquer cracks
  • A «prediction» study, not «treatment comparison»: deliberately excluded atropine/ortho-K/red-light users; says nothing about which control is best
  • Extrapolate cautiously: single centre, Han-Chinese children, model not externally validated; individual assessment of Taiwanese children stays with your ophthalmologist

4. What is myopic maculopathy? The Meta-PM grading

Myopic maculopathy (MM) is high myopia's most important and feared complication — a leading cause of irreversible vision loss in industrialised countries. Its root mechanism: the axial length (front-to-back length of the eye) elongates excessively, mechanically stretching and thinning the retina, choroid, and sclera at the posterior pole (where the macula sits), causing progressive structural degeneration. Internationally it is graded into five categories by the Meta-analysis for Pathologic Myopia (Meta-PM) system:

CategoryFundus changeMeaning
C0No myopic retinal changeNormal
C1Tessellated fundusEarliest; choroid thinning begins
C2Diffuse chorioretinal atrophyEnters «pathologic myopia» range
C3Patchy chorioretinal atrophyFocal full atrophy; vision affected
C4Macular atrophyMost severe; severe central vision loss

Beyond these five, three «plus» lesions warrant special vigilance: lacquer cracks (LCs) — mechanical breaks in Bruch's membrane; Fuchs spot; and choroidal neovascularization (CNV) — which bleeds and causes acute vision loss. The study defined pathologic myopia (PM) as worse than C1 or the presence of any plus lesion.

5. How was the study done? (8-year prospective cohort)

This was a hospital-based prospective cohort at Zhongshan Ophthalmic Center, Guangzhou. Enrolled 2011–2012: children/adolescents aged 7–17 with high myopia (SE ≤ −6.0 D), followed every 2 years for 8 years. Ultimately 155 participants / 310 eyes completed the full 8-year follow-up and were analysed. Each visit measured: axial length (Lenstar optical biometry; IOLMaster if >32 mm), cycloplegic refraction, corrected acuity, IOP, and dilated macula- and disc-centred fundus photography. Fundus images were graded by senior ophthalmologists trained in Meta-PM, with good inter-grader agreement (kappa 0.73–0.84). To cleanly observe natural progression, children using orthokeratology, low-dose atropine, repeated low-level red-light therapy, or who had refractive/intraocular surgery were excluded.

Over 8 years, mean age rose from 13.6 to 22.0; axial length increased from 27.03 to 28.01 mm; SE deepened from −9.18 to −11.77 D. Even into early adulthood, high myopia kept progressing.

6. Core result: axial-length change predicts progression

The study used GEE logistic regression to identify predictors of 8-year maculopathy progression and compared model accuracy (area under the ROC curve, AUC; closer to 1.0 = better):

Prediction modelFactorsAUC
Model 1 (baseline AL)age + PM + baseline AL0.772
Model 2 (+AL change)Model 1 + 2-year AL change rate0.829
Model 3 (baseline SE)age + PM + baseline SE0.764
Model 4 (+SE change)Model 3 + 2-year SE change rate0.793

Three points: (1) Adding the «2-year AL change rate» markedly improved prediction (0.772 → 0.829, P=.013) — the paper's key message: short-term axial change carries independent information about long-term complications. (2) SE-based versions (Models 3, 4) were slightly less accurate than AL-based ones, again supporting axial length as the better progression marker. (3) After bootstrap internal validation, the optimism-corrected AUC was still 0.821 with minimal optimism (0.008), indicating internal stability. Baseline AL (OR 1.62), 2-year AL change rate (OR 1.62 per 0.1 mm/yr), and pathologic myopia (OR 6.26) were all significant predictors.

7. The 0.325 mm/year cut-off: how to use it (and not misuse it)

Using Youden's index on the ROC curve, the axial-growth speed that best separated «will progress vs won't» was about 0.325 mm/year. Its correct use: a reference line to flag a child into the «needs closer attention» group. But it is easily misused — remember:

⚠️ Reading the cut-off correctly

  • A population boundary, not a personal guarantee: above it doesn't mean certain progression; below it isn't absolute safety.
  • A research value, not a diagnostic line: from a single-centre specific population; not for self-interpretation or panic.
  • A triage tool, not a treatment order: it helps flag who needs more aggressive control/follow-up, but the method and interval are the ophthalmologist's call.
  • Normal children's eyes grow anyway: axial elongation is natural during development; the point is whether it's «too fast for a high-myopia child», judged by the doctor against age and baseline.

8. Why does axial elongation damage the macula?

Think of the eye as a balloon: as the axial (front-to-back) length is «blown» longer, the wall at the posterior pole stretches thinner. This mechanical stretch triggers a cascade:

🔬 Axial elongation → maculopathy mechanism chain

  • Scleral remodeling and thinning: the eye wall's (scleral) collagen is rearranged and thinned, losing support, so the posterior pole bulges backward (sometimes forming a posterior staphyloma).
  • Choroidal thinning: the choroid is the vascular layer feeding the outer retina; once thinned, blood flow and oxygen drop, and the outer retina becomes ischaemic and degenerates — the basis of tessellation progressing to atrophy.
  • Mechanical breaks in Bruch's membrane (lacquer cracks): stretching the RPE–Bruch's–choriocapillaris complex to its limit causes cracks (lacquer cracks), a launchpad for choroidal neovascularization (CNV) — and CNV bleeding can cause acute central vision loss.

This chain explains why «fast axial growth» is such a strong predictor: rapid elongation = rapid stretching of posterior-pole tissue = accelerated degeneration. So a core goal of controlling myopia progression is to slow axial elongation, reducing future maculopathy risk at its source.

9. Study limitations

⚠️ 5 limitations to remember

  • Single centre, specific population: one Guangzhou centre, mainly Han-Chinese children; Taiwanese children are similar but extrapolation needs caution.
  • Model not externally validated: only internal bootstrap validation so far; the cut-off and AUC may differ in other populations.
  • Posterior staphyloma not assessed: 45° fundus photos may miss staphylomas beyond the posterior pole, possibly underestimating true prevalence.
  • Non-blinded grading: graders knew baseline vs follow-up, a theoretical classification-bias risk (minimised by inter-rater agreement and standardisation).
  • Follow-up rate not optimal: long-term attrition is inevitable (~36% finally analysed); but participants and dropouts didn't differ significantly at baseline, so selection bias is likely limited.

10. Taiwan context and NHI notes

⚠️ Costs & coverage — confirm with your care team and the latest NHIA rules

  • Taiwan is also a high-myopia region: East-Asian children have among the world's highest myopia and high-myopia rates, so this Han-Chinese study is highly relevant to Taiwanese families — but individual assessment stays with your ophthalmologist.
  • Costs/coverage of myopia-control treatments: low-dose atropine, ortho-K, special optical-design lenses, red-light therapy each have different and changing NHI/self-pay status; refer to your hospital's pre-service notice and the latest NHIA announcements. No individual claims here.
  • Axial-length measurement and fundus exams: not every clinic has optical biometry; for a highly myopic child wanting regular axial-length and dilated-fundus monitoring, ask your clinic about equipment and scheduling.
  • Outdoor time: increasing outdoor activity is one of the few well-evidenced, zero-cost, generally healthy myopia-prevention strategies — worth building as a habit from a young age.

11. Red flags: when a high-myopia child needs prompt care

🚨 Red flags for high-myopia children

  • Sudden flashes, a surge of new floaters, or a curtain/shadow over part of the vision — warns of retinal detachment (high-myopia high risk); seek same-day care
  • Central distortion/warping, or a blurred dark patch in the centre — possible CNV bleeding or maculopathy progression
  • Marked unilateral vision drop over a short time — don't assume it's «just more myopia»; get a prompt fundus exam
  • Markedly accelerated axial growth at follow-up — not an emergency, but discuss adjusting the myopia-control strategy with your doctor

The first three are acute warning signs that can threaten vision — seek same-day care; even without symptoms, high-myopia children should attend regular axial-length and dilated-fundus follow-up.

12. Conclusion: turning axial length from a «glasses number» into an early-warning tool

The most valuable contribution of this 8-year study is elevating «axial length» from a number that merely sets glasses power into an early tool for predicting future maculopathy. It tells us two practical things: (1) about one-third of high-myopia children's maculae change within 8 years — this is not a distant old-age disease; (2) simply watching how fast axial length grows in the first 2 years can fairly accurately flag future high-risk children.

Three practical messages for parents: (1) High-myopia children must have regular follow-up that includes axial length and a dilated fundus exam — not just a refraction and new glasses. (2) Fast axial growth is a warning sign — it means more aggressive myopia control is warranted, but the method is for the ophthalmologist to decide. (3) The earlier you start, the more you protect the macula — younger children have many growth years ahead, so controlling axial elongation early is buying insurance for vision decades later. Controlling myopia ultimately protects not just «how clearly you see» but «whether the fundus breaks down».

📚 HsiaoEye Related Articles — Pediatric Myopia / Retina

References

  1. Jiang F, Wang L, Ding X, He M, Zeng J, Li Z. Short-Term Axial Length Changes Predict Progression of Myopic Maculopathy in Pediatric High Myopia. Am J Ophthalmol. 2026;287:188–197. doi:10.1016/j.ajo.2026.03.022
  2. Ohno-Matsui K, Kawasaki R, Jonas JB, et al; META-analysis for Pathologic Myopia (META-PM) Study Group. International photographic classification and grading system for myopic maculopathy. Am J Ophthalmol. 2015;159(5):877–883.
  3. Ohno-Matsui K, Lai TYY, Lai CC, Cheung CMG. Updates of pathologic myopia. Prog Retin Eye Res. 2016;52:156–187.
  4. Fang Y, Yokoi T, Nagaoka N, et al. Progression of myopic maculopathy during 18-year follow-up. Ophthalmology. 2018;125(6):863–877.
  5. Tideman JWL, Snabel MCC, Tedja MS, et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia. JAMA Ophthalmol. 2016;134(12):1355–1363.
  6. Hu Y, Ding X, Long W, et al. Longitudinal changes in choroidal thickness and its relationship with myopic progression in children. Br J Ophthalmol. 2021;105(11):1542–1547.
  7. Wong YL, Sabanayagam C, Ding Y, et al. Prevalence, risk factors, and impact of myopic macular degeneration on visual impairment. Invest Ophthalmol Vis Sci. 2018;59(11):4603–4613.
  8. Bullimore MA, Brennan NA. Myopia control: why each diopter matters. Optom Vis Sci. 2019;96(6):463–465.

Frequently asked questions

How likely is maculopathy progression in 8 years for high-myopia children?
In this 8-year study of 310 high-myopia children's eyes, about 1 in 3 (31.3%, 97 eyes) showed maculopathy progression, most commonly a newly appearing tessellated fundus (44.6%). To be clear, most were early changes (normal to tessellated) and progression does not equal blindness; only a few reached severe atrophy.
Why measure axial length, and how is it different from the prescription?
Axial length is the eye's actual front-to-back length, measured directly by optical biometry; it reflects true elongation and is a more stable, objective progression marker than refraction, which is affected by the cornea, lens accommodation, and the moment of testing. This study found that adding the first 2-year axial-length change rate raised the accuracy (AUC) of predicting 8-year maculopathy progression from 0.772 to 0.829.
What does the 0.325 mm/year cut-off mean, and does exceeding it guarantee trouble?
This is a reference line found with Youden's index for the axial-growth speed that best separated progressors from non-progressors, about 0.325 mm/year. It is a population-level risk boundary, not a personal diagnostic threshold that means blindness if crossed. It comes from a single-centre, specific population, so Taiwanese children may differ; whether you are truly high-risk and whether to adjust treatment is for your ophthalmologist to judge holistically.
Which high-myopia children are most at risk, and what are the high-risk features?
The study highlights several high-risk features: fast axial growth in the first 2 years (>=0.325 mm/year), high myopia at a younger age (progressors averaged 12.9 years), very deep refraction and longer axis (progressors averaged about -10.7 D and 27.7 mm), already having pathologic myopia (~6x higher risk), and already having lacquer cracks. The more features present, the greater the need for aggressive control and more intensive follow-up.
Did this study say which myopia-control method is best?
No. This is a prediction study, not a treatment-comparison study; to cleanly observe natural progression, it deliberately excluded children using orthokeratology, low-dose atropine, or repeated low-level red-light therapy. Its message is to identify who is high-risk and needs close monitoring, not which drug to use. Each myopia-control tool has its own evidence and indications and should be chosen by the ophthalmologist based on the child's age, refraction, axial-progression speed, and adherence.
How often should high-myopia children be checked, and with what tests?
Frequency and tests are set by the ophthalmologist based on individual risk. This study did a full assessment every 2 years, with key items being axial length (optical biometry) to track elongation speed, and dilated macula and optic-disc fundus photography graded by Meta-PM, plus corrected acuity, intraocular pressure, and refraction. In practice, if refraction or axial length progresses fast, the doctor may shorten the interval to every 6 to 12 months and add OCT as needed.