For children with early-onset progressive high myopia, the concern is not limited to stronger glasses or longer eyeballs. Over time, high myopia can be associated with structural changes at the back of the eye, including fundus tessellation, choroidal thinning, and myopic maculopathy. These changes may accumulate over many years and increase the risk of future visual impairment. This means that evaluating high myopia interventions should not rely only on refractive error and axial length, but should also consider whether the fundus is undergoing early structural deterioration.
A study published in Eye Discovery provides new evidence from this perspective. Researchers from the Eye & ENT Hospital of Fudan University and the Key Laboratory of Myopia and Related Eye Diseases evaluated three-year changes in refractive status, axial length, and quantitative fundus parameters in children with progressive high myopia who underwent posterior scleral reinforcement (PSR). The procedure used a crosslinked bovine pericardial patch, with the aim of reinforcing the posterior part of the eye and exploring its potential effect on high myopia-related fundus changes.
Posterior scleral reinforcement is not a new surgical concept. It was first proposed in the 1930s and later modified through different surgical techniques and implant materials. The basic idea is to strengthen the posterior sclera and reduce further expansion of the highly myopic eye. However, PSR has remained controversial because previous studies have varied substantially in design, patient characteristics, and materials, and robust large-scale randomized evidence remains limited.
In this prospective case-control study, 69 children were enrolled: 37 underwent bilateral PSR and 32 served as non-surgical controls. The control children were matched by age, spherical equivalent, and axial length, but had slower myopia progression of less than −1.00 D per year. The researchers noted that randomizing rapidly progressing children to a non-surgical control group was considered ethically inappropriate, because it could potentially withhold an established intervention for progressive high myopia. At the three-year follow-up, 12 participants were lost to follow-up, including 7 in the PSR group and 5 in the control group.
The first important finding was a boundary: PSR did not show a significant between-group advantage in conventional myopia progression indicators. Over three years, the change in spherical equivalent was −1.23 ± 0.89 D in the PSR group and −1.60 ± 1.15 D in the non-PSR group, with no statistically significant difference. Axial length increased by 0.70 ± 0.43 mm in the PSR group and 0.80 ± 0.53 mm in the non-PSR group, also without a significant between-group difference. In other words, this study should not be interpreted as showing that PSR significantly controlled refractive progression or axial elongation in children with high myopia.
The more notable findings came from quantitative fundus analysis. Using ultra-widefield fundus imaging and a deep learning-based image analysis system, the researchers measured fundus tessellated density (FTD), an objective indicator of the severity of fundus tessellation. Fundus tessellation, characterized by visible choroidal vessels in the posterior fundus, is considered one of the earliest signs of myopic maculopathy. Over three years, macular FTD changed by −0.65 ± 5.74% in the PSR group, compared with 3.69 ± 3.80% in the non-PSR group, a statistically significant difference.
Another key result involved subfoveal choroidal thickness (SFCT), a structural measure of the choroid beneath the fovea. The PSR group showed a smaller reduction in SFCT over three years, with a change of −9.93 ± 20.14 μm, compared with −23.07 ± 15.23 μm in the non-PSR group. The non-PSR group also showed significant worsening of macular FTD and significant thinning of SFCT during follow-up, whereas SFCT did not decrease significantly within the PSR group.
Together, these results suggest that the potential value of PSR may not be captured only by refractive error or axial length. Although the study did not find significant between-group differences in axial elongation or spherical equivalent progression, children who underwent PSR showed slower progression of macular fundus tessellation and better preservation of subfoveal choroidal thickness. The researchers suggest that PSR may help delay early myopic maculopathy-related fundus changes, possibly through mechanisms beyond simply restricting axial elongation.
This mechanism, however, remains uncertain. The study found no significant correlation between changes in SFCT and changes in axial length or spherical equivalent in either group. This suggests that choroidal preservation may not be directly linked to the degree of axial elongation or refractive progression. Further studies using optical coherence tomography angiography, widefield OCT, or three-dimensional imaging may help clarify whether changes in choroidal perfusion, posterior staphyloma morphology, or scleral structure contribute to the observed fundus differences.
The study also has important limitations. It was not randomized. For ethical reasons, children in the PSR group had rapidly progressive high myopia, while the control group consisted of children with naturally slower progression, which may have introduced selection bias. The sample size was relatively small, and some participants were lost to follow-up. In addition, OCT angiography was not performed, so postoperative changes in choroidal blood flow could not be directly evaluated. Central macular thickness was also not included as a primary structural outcome.
Overall, this study shifts attention from the traditional myopia-control endpoints of refractive error and axial length toward quantitative fundus structure. It suggests that, in children with progressive high myopia, PSR using a crosslinked bovine pericardial patch may help slow early macular fundus changes and better preserve subfoveal choroidal thickness. However, larger, longer-term randomized controlled trials are still needed to validate the efficacy of PSR, optimize surgical materials and techniques, and define its role in the prevention and management of pediatric high myopia.
Article information:
Longitudinal quantitative fundus changes after posterior scleral reinforcement in children with progressive high myopia .
Eye Discovery , 2026.
Article Link: Https://doi.org/10.1016/j.edisc.2026.100053 .
About Eye Discovery
Eye Discovery is an open-access, peer-reviewed international academic journal, with ISSN 3117-4167. It is published quarterly by Elsevier and serves as the official journal of Eye & ENT Hospital of Fudan University, China.
Eye Discovery is dedicated to creating a high-end platform for ophthalmologists, scientists, and scholars worldwide to focus on innovative achievements in ophthalmology and interdisciplinary fields, and to promote academic dissemination and exchange.
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Longitudinal quantitative fundus changes after posterior scleral reinforcement in children with progressive high myopia
9-Aug-2026