Myopic traction maculopathy (MTM) is a maculopathy in highly myopic eyes accompanied by any of the following tractional retinal changes: epiretinal membrane, vitreomacular traction, lamellar hole, retinal thickening, macular hole, retinoschisis, or tractional retinal detachment. It is also called myopic foveoschisis.
In 1958, Phillips first described localized posterior pole retinal detachment in patients with high myopia and posterior scleral staphyloma. Before the advent of OCT, it was difficult to distinguish from shallow retinal detachment or macular hole. In 1999, Takano and Kishi first reported detection of MTM using OCT, and the term “MTM” was subsequently proposed.
MTM is estimated to occur in 9–34% of highly myopic eyes with posterior staphyloma. It may be more common in women. There is an exponential relationship between the degree of myopia and the prevalence of myopic maculopathy; the prevalence increases by approximately 58% for each diopter increase in myopia 7).
Pathologic myopia is the second leading cause of visual impairment in Japan (13% of visual impairment with corrected visual acuity ≤0.1, after glaucoma), and myopic traction maculopathy is one of its important complications.
Macular holes in highly myopic eyes are more likely to progress to retinal detachment than idiopathic macular holes, so caution is needed.
It is found in 9–34% of highly myopic eyes with posterior staphyloma. The frequency is higher in populations with a high prevalence of high myopia.
Subjective symptoms of MTM are diverse and may be asymptomatic.
In highly myopic eyes, the fundus appears tigroid, making it difficult to accurately assess the macular region with ophthalmoscopy. OCT is essential for diagnosis, and the following characteristic findings are observed.
Fundus examination typically reveals findings associated with degenerative myopia, such as chorioretinal atrophy, peripapillary atrophy, posterior staphyloma, and lacquer cracks.
The development of MTM is multifactorial, involving multiple tractional mechanisms and structural factors.
Anterior Traction
Vitreomacular traction: Incomplete posterior vitreous detachment causes the vitreous to pull the macula anteriorly.
Residual cortical vitreous: Even when posterior vitreous detachment appears to have occurred, a thin layer of residual vitreous cortex often remains strongly adherent to the retinal surface.
Epiretinal membrane: Adds tangential traction and is a poor prognostic factor.
Retinal vascular traction: Stiffening and straightening of blood vessels cause traction.
Posterior Traction
Posterior staphyloma: Age-related morphological expansion generates a force that pulls the retina posteriorly.
Rigidity of the internal limiting membrane: Because the internal limiting membrane is stiff, the retina cannot follow the shape changes of the staphyloma.
Chorioretinal atrophy: Atrophy reduces retinal adhesion, making it more prone to separation or detachment.
The natural course of MTM varies greatly among cases. While some eyes remain stable for years, others progress to severe complications such as full-thickness macular hole or foveal detachment. Extensive macular detachment (S4) and the presence of premacular tissue are risk factors for progression5). Spontaneous resolution has been reported in approximately 3.9% of cases4).
In highly myopic eyes, elongation of the axial length can cause breaks in Bruch’s membrane, which may lead to myopic choroidal neovascularization (CNV). The incidence of myopic CNV is reported to be 5–11% in high myopia 5), and it can coexist with MTM.
Posterior staphyloma is a major factor in the development of MTM, but multiple factors such as internal limiting membrane rigidity, epiretinal membrane, and vitreous traction also interact. The degree of traction varies depending on the shape and size of the staphyloma.
OCT is essential for diagnosing MTM. In highly myopic eyes, fundus findings alone are insufficient for detailed evaluation of the macula, and OCT is also needed to differentiate from shallow retinal detachment or macular hole.
Spectral-domain OCT (SD-OCT) and swept-source OCT (SS-OCT) show high detection sensitivity. Evaluation items are as follows:
The stage classification of retinoschisis is shown below5).
| Stage | Extent of schisis | Characteristics |
|---|---|---|
| S0 | None | No schisis |
| S1 | Extra-foveal | Peripheral only |
| S2–S3 | Involving fovea | Partial |
| S4 | Whole macula | Prone to progression |
Even in cases with poor fixation or extrafoveal fixation, which are common in high myopia, scanning a certain area with spectral-domain OCT is useful for evaluating the presence of macular hole or macular detachment.
Diseases that require differentiation from MTM include the following:
The treatment strategy for MTM is controversial. The natural course is unclear, and the risk of complications from surgical intervention cannot be ignored.
For stable cases or those with preserved vision, regular follow-up with OCT is the basic approach. If visual acuity decreases at the stage of retinoschisis alone, vitrectomy can be expected to improve vision within six months to one year after surgery.
Surgery is considered in the following cases.
Vitrectomy
Pars plana vitrectomy (PPV) + internal limiting membrane peeling: Releases anterior traction on the macula and removes the scaffold for cell proliferation. Anatomical resolution and visual improvement can be achieved even without gas tamponade.
Fovea-sparing internal limiting membrane peeling: A method that reduces the risk of iatrogenic macular hole by preserving the internal limiting membrane at the fovea. Limited studies have shown good outcomes5).
Internal limiting membrane flap technique: A technique in which the internal limiting membrane is left as a flap without complete peeling and placed over the macular hole. Compared to internal limiting membrane peeling alone, it has higher rates of retinal reattachment (97.8% vs 82%) and macular hole closure (93.5% vs 38.5%)2).
Macular Buckle
Macular buckle surgery: A procedure in which scleral buckle material is placed at the posterior pole to push up the staphyloma from the outside. It has a mechanical effect of bringing the RPE closer to the retina.
Advantages: Avoidance of cataract development and avoidance of iatrogenic macular hole associated with internal limiting membrane peeling. It directly addresses the structural cause of staphyloma1).
Outcomes: Macular buckle alone or combined with vitrectomy has been reported to have higher anatomical success rates and better functional outcomes than vitrectomy alone2).
In refractory cases, macular buckling or scleral shortening may be performed. For macular hole retinal detachment, vitrectomy or gas injection is indicated.
The following factors have been reported to influence postoperative visual and anatomical outcomes.
After surgery, it may take several months or more for the retina to reattach. Vitrectomy achieves final reattachment in almost all cases, but visual prognosis depends on the condition of the macula before and after surgery. Cases with preoperative macular detachment have the best visual prognosis, while those with preoperative macular hole or postoperative macular hole have poor visual prognosis.
Surgery is indicated when there is visual impairment or concern for progression to macular hole or tractional retinal detachment. Early surgery is recommended when foveal detachment is progressing 5). On the other hand, observation is an option when only stable retinoschisis is present.
Formation of iatrogenic macular holes is known as a serious complication of internal limiting membrane peeling. The risk is high in highly myopic eyes because the internal limiting membrane is thin and prone to tearing. Fovea-sparing internal limiting membrane peeling is an option to reduce this risk 5).
The pathophysiology of MTM is multifactorial, involving three main tractional mechanisms 5).
Resolution of separation after vitrectomy with ILM peeling supports the importance of anterior traction, while the success of scleral buckling supports the involvement of posterior traction and ILM rigidity.
Histopathologically, separation cavities form in various layers of the neurosensory retina at the macula, including the outer plexiform layer, inner plexiform layer, and nerve fiber layer. They commonly occur between the Henle fiber layer and the photoreceptor layer, with Müller cells stretching but maintaining connections between the two layers.
Choroidal perfusion impairment has been considered as a possible contributor to MTM 3). If the choroid cannot supply sufficient oxygen and nutrients to the outer retina, the adhesion between the retina and RPE may weaken, allowing even slight traction to cause detachment. However, some cases show no clear perfusion deficiency on choroidal thickness or angiography, so the mechanism is not fully understood.
Müller cell dysfunction is also thought to be a factor in MTM. Müller cells are involved in regulating intracellular fluid and metabolic water, and structural abnormalities may lead to increased fluid influx and cavity formation 4).
Clark et al. (2024) reported a “macular sling” technique for creating a customized posterior buckle using general scleral buckle materials (41 band, 240 band, 509G sponge) for facilities where dedicated macular buckle devices are not available 1). Using this technique for recurrent complex tractional retinal detachment, subretinal fluid resolved one week postoperatively, and visual acuity recovered to the preoperative baseline (20/70).
Parolini et al. (2025) performed a procedure in two cases of refractory macular hole resistant to initial surgery (vitrectomy + ILM flap + gas tamponade), where after macular buckle placement, balanced salt solution (BSS) was injected subretinally to induce controlled macular detachment 2). In both cases, the macular hole closed, and in case 1, visual acuity improved from 1.0 logMAR to 0.4 logMAR.
Murillo et al. (2022) reported a new technique for a highly myopic macular hole (958 μm) with macular detachment, in which the anterior lens capsule was bisected and inserted into the hole, and the internal limiting membrane was placed transversely 6). Utilizing the biological and mechanical properties of the anterior capsule (scaffold for cell proliferation, elasticity, selective permeability), visual acuity improved from 20/600 to 20/80 one year postoperatively, and the macular detachment resolved.
Kokame et al. (2025) reported a case of myopic foveoschisis complicated by a full-thickness macular hole, in which the macular hole closed and the schisis markedly improved with only topical treatment of 1% prednisolone eye drops (4 times daily) and 0.07% bromfenac eye drops (once daily) 4). Visual acuity recovered from 20/50 to 20/20. The spontaneous resolution rate of MTM is about 3.9%, and this is the first report of resolution with topical treatment.
