Eye Shape May Predict Progression Risk in Pathologic Myopia

A 15-year prospective study published in JAMA Ophthalmology found MRI-defined eye shape may help predict progression risk in pathologic myopia beyond traditional measures such as axial length and refractive error. Nasally distorted and conical eyes demonstrated the greatest risks for axial elongation, choroidal thinning and visual field loss, though unresolved questions involving globe deformation measurements, biomechanical stress and longitudinal changes in morphology warrant further study. Photo: Andrew Rouse, OD. Click image to enlarge. As the global public health crisis surrounding high myopia continues to progress, researchers are attempting to understand various mechanisms that can stratify risk and outcomes among certain populations. In pathologic myopia specifically, which is marked by structural lesions, traditional risk metrics such as axial length, refractive error and demographic factors do not adequately capture the substantial heterogeneity in disease progression. However, evidence is emerging that suggests eye shape may be associated with long-term high myopia structural and functional trajectories, and a new study published in JAMA Ophthalmology claims to support this hypothesis.1 This prospective cohort study involved individuals with high myopia (≤ -6D in both eyes) between the ages of seven and 70 years enrolled at a single center in China. Participants were followed biennially over 15 years beginning in August 2011 through September 2025. Eye shape was defined by high-resolution MRI and classified into six categories: spheroidal, ellipsoidal, conical, nasally distorted, temporally distorted and barrel shaped. Spheroidal and ellipsoidal types were defined as nondeformed and the others as deformed. Ultimately, 152 eyes from 78 participants were included in the analysis, of which 50.7% were female, with an overall mean age of 32.3. Baseline shapes included spheroidal (54.6%), nasally distorted (16.4%), conical (15.1%), ellipsoidal (7.2%), temporally distorted (3.3%) and barrel shaped (3.3%). The primary outcomes were as follows:Axial elongation followed a morphology-dependent gradient, from slowest in spheroidal eyes (0.045mm/y) to fastest in nasally distorted eyes (0.095mm/y). Nasally distorted eyes elongated by 0.050mm/y faster and had higher odds of rapid elongation (odds ratio, 5.74). Deformed eyes overall had a sevenfold higher risk of macular choroidal thinning (odds ratio, 7.24). Nasally distorted and conical eyes showed the greatest risks for both choroidal thinning and myopic macular degeneration progression.Posterior staphyloma risk differed across baseline eye shapes. Deformed eyes overall had a 2.75-fold higher risk, and conical and temporally distorted eyes also showed higher odds ratios by some measures.For visual field defects, risk was elevated in nasally distorted and conical eyes. The authors further summarized the results in their paper, writing, “Among the six morphological subtypes, nasally distorted eye showed the highest overall risk, with rapid axial elongation, accelerated choroidal thinning and marked deterioration in both BCVA and VF.” Conical eyes also exhibited a high-risk profile, they wrote, particularly for choroidal thinning and VF loss, whereas barrel-shaped eyes showed large effect estimates but were limited by small sample size. Temporally distorted eyes and ellipsoidal eyes showed lower overall risk of severe complications. “These findings suggest substantial heterogeneity in the natural history” of high myopia and suggest that “eye shape provides prognostic information beyond AL, supporting individualized surveillance and precision intervention strategies” in pathologic myopia, they continued.An invited commentary on this study, also published in JAMA Ophthalmology, argues that, while the findings represent “an important and timely contribution to our understanding of pathologic myopia,” several methodological considerations merit further discussion.2 The author—Kyoko Ohno-Matsui, MD, PhD, professor and chair of the Department of Ophthalmology and Visual Science at Tokyo Medical and Dental University—first points out axial length as a key outcome measure. “In highly myopic eyes, the fovea is frequently displaced from the deepest point of the globe, often nasally or superiorly. This discrepancy may introduce bias in estimating true axial length elongation relative to overall globe deformation,” she wrote. “Future studies incorporating geometric correction for foveal position or using alternative metrics of globe expansion may provide a more accurate representation of structural progression.”Dr. Ohno-Matsui also questioned the increased risk of staphyloma in deformed eyes and whether ultra-widefield OCT was systematically used, as well as discrepancies with earlier studies that suggested abrupt changes in scleral curvature could contribute to nerve fiber damage. “In the present study, although the risk patterns differ, a similar biomechanical mechanism may be relevant, particularly in nasally distorted eyes where curvature changes around the peripapillary region may exert mechanical stress on the optic nerve,” she wrote.The commentary also wonders how eye shape itself evolves over time. In the cohort study, eye shape was determined based on baseline MRI only, not considering how pathologic myopia is a dynamic process. “Repeated 3D-MRI imaging in the same cohort would be highly valuable to determine whether eyes transition between subtypes and how such changes relate to disease progression,” Dr. Ohno-Matsui wrote.“This study provides strong longitudinal evidence that eye shape is a key determinant of long-term outcomes in pathologic myopia. It moves the field beyond conventional metrics toward a more comprehensive understanding of ocular biomechanics,” the commentary concluded. “Future work integrating multimodal imaging, quantitative shape analysis and longitudinal morphological assessment will be essential to translate these findings into clinical practice. Ultimately, a morphology-based approach may enable more precise prediction of disease progression and guide targeted interventions to prevent vision loss.”Click here for the journal source and here for the commentary. Xiong R,Tan S,Li Y, et al. Pathologic myopia globe shape and long-term prognosis. JAMA Ophthalmology. May 28, 2026. [Epub ahead of print.]Ohno-Matsui K. 3D globe shape and long-term structural and functional outcomes in pathologic myopia. JAMA Ophthalmology. May 28, 2026. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.