Cataract surgery in highly myopic eyes demands a whole different playbook

Cataract surgery in highly myopic eyes is anything but routine. When axial length surpasses 26 mm, the eye's structural mechanics shift dramatically — deeper anterior chambers, larger capsular bags, thinner sclera, weaker zonules, and a vulnerable posterior segment all raise the surgical stakes. Treating these cases like standard procedures risks serious complications, including lens-iris diaphragm retropulsion syndrome, capsular rupture, and postoperative retinal damage.

Preparation starts well before the OR. Surgeons should use modern IOL power formulas (like Barrett Universal II) optimized for long eyes, target slight residual myopia rather than plano to avoid hyperopic surprises, and conduct a thorough dilated retinal exam — high myopes carry significantly elevated risk for lattice degeneration, retinal tears, and staphylomas. Patients also need clear counseling: gaining distance vision means permanently losing their built-in near focal point.

Key Takeaways:

• Aim for a 5–5.5 mm capsulorrhexis to prevent phimosis or optic decentralization
• Use gentle hydrodissection to avoid stressing fragile zonules or the posterior capsule
• Bring the nucleus to the supracapsular space or iris plane to reduce posterior capsule rupture risk
• Monitor IOP closely postoperatively and maintain a low threshold for retina subspecialist referral

Why it matters: High myopes have often struggled with poor vision their entire lives. With the right surgical approach, refractive cataract surgery — including toric IOLs for astigmatism — can be genuinely life-changing for these patients.