Pathological Myopia and Myopic Maculopathy: META-PM and ATN Grading
Last updated: November 2026
High myopia (−6 D or axial length over 26 mm) is rising fast across Asia. Pathological myopia means degenerative changes in the macula and posterior pole, and it is now a leading cause of irreversible visual loss in working-age adults.
META-PM classification (2015)
| Category | Fundus finding |
|---|---|
| 0 | No myopic retinal lesions |
| 1 | Tessellated (tigroid) fundus |
| 2 | Diffuse chorioretinal atrophy |
| 3 | Patchy chorioretinal atrophy |
| 4 | Macular atrophy |
"Plus" lesions are added to any category: lacquer cracks, myopic choroidal neovascularisation (CNV), and Fuchs spot. Pathological myopia is category 2 or more, any plus lesion, or a posterior staphyloma.
ATN system (2019)
Grades Atrophic (A0–A4, mirrors META-PM), Tractional (T0–T5: from inner retinal thickening and foveoschisis to macular hole and detachment) and Neovascular (N0, N1 lacquer cracks, N2a active CNV, N2s Fuchs spot) components separately. Severe pathological myopia includes A3 or more, T2 or more, or N2.
Key complications
| Problem | Management |
|---|---|
| Myopic CNV | Sudden distortion or a central blur; small subfoveal lesion; anti-VEGF injections (often fewer needed than in AMD); OCT and FFA |
| Myopic traction maculopathy (foveoschisis) | Observe if vision is stable; vitrectomy with ILM peel (fovea-sparing) if vision falls or a hole or detachment develops |
| Macular hole and retinal detachment | Higher risk; macular hole retinal detachment needs vitrectomy |
| Others | Glaucoma (hard to diagnose with tilted discs), early cataract, peripheral degenerations |
Prevention
Slowing myopia progression in children (low-dose atropine, myopia control lenses, outdoor time) reduces the risk of pathological myopia later. See myopia control.
Where residents slip
- Missing myopic CNV by attributing new distortion to "old myopia".
- Diagnosing glaucoma from a tilted myopic disc alone.
- Forgetting peripheral retina examination in high myopes.
Test yourself: flip cards
Related: Myopia Control in 2026: Atropine, Lenslet Spectacles, Ortho-K and Red Light, OCT Macula Reference Card: Normal Thickness, DME and Hole Staging, AMD: The Current Anti-VEGF Landscape.
Key sources
- Ohno-Matsui K, et al. International photographic classification and grading system for myopic maculopathy (META-PM). Am J Ophthalmol. 2015;159:877-883
- Ruiz-Medrano J, et al. Myopic maculopathy: current status and proposal for a new classification and grading system (ATN). Prog Retin Eye Res. 2019;69:80-115
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