3D growth and remodeling theory supports the hypothesis of staphyloma formation from local scleral weakening under normal intraocular pressure.

The purpose of this study was to assess whether growth and remodeling (G&R) theory could explain staphyloma formation from a local scleral weakening-as could occur from age-related elastin degradation, myopia progression, or other factors. A finite element model of a healthy eye was reconstructed, including the lamina cribrosa, the peripapillary sclera, and the peripheral sclera. The homogenized constrained mixture model was employed to simulate the adaptation of the sclera to alterations in its biomechanical environment over a duration of 13.7 years. G&R processes were triggered by reducing the shear stiffness of the ground matrix in the peripapillary sclera and lamina cribrosa by 85%. Three distinct G&R scenarios were investigated: (1) low mass turnover rate in combination with transmural volumetric growth; (2) high mass turnover rate in combination with transmural volumetric growth; and (3) high mass turnover rate in combination with mass density growth. In scenario 1, we observed a significant outpouching of the posterior pole, closely resembling the shape of a Type-III staphyloma. Additionally, we found a notable change in scleral curvature and a thinning of the peripapillary sclera by 84%. In contrast, scenario 2 and 3 exhibited less drastic deformations, with stable posterior staphylomas after approximately 7 years. Our proposed framework suggests that local scleral weakening is sufficient to trigger staphyloma formation under a normal level of intraocular pressure. Our model also reproduced characteristics of Type-III staphylomas. With patient-specific scleral geometries (as could be obtained with wide-field optical coherence tomography), our framework could be clinically translated to help us identify those at risks of developing posterior staphylomas.