With the global rise in high myopia and its associated risk of vision-threatening complications, optimising cataract surgery in this population is becoming increasingly important.
In this Expert Pearl, Prof. Andrzej Grzybowski explores why cataract surgery in high myopia should be approached as more than a routine procedure. From complex biometry and IOL selection to retinal risk and patient expectations, he outlines the key considerations needed to optimise outcomes in this challenging patient population.
Cataract surgery in highly myopic eyes requires a fundamentally different approach than routine age-related cataract surgery. These eyes represent a distinct clinical entity, where anatomical alterations, retinal vulnerability, and refractive unpredictability all converge to influence outcomes.
Preoperatively, careful evaluation is critical and extends far beyond standard cataract assessment. A thorough examination of both the central and peripheral retina is mandatory, given the high prevalence of lattice degeneration, retinal tears, and myopic maculopathy in these patients. Optical coherence tomography is often required to assess macular status, while widefield imaging or indirect ophthalmoscopy helps identify peripheral pathology. This step is essential not only for surgical planning but also for estimating visual prognosis and preventing postoperative complications. In addition, glaucoma screening should be routinely performed, as structural changes in highly myopic eyes may mask optic nerve damage. Biometry presents another major challenge. Posterior staphyloma and fixation instability can lead to inaccurate axial length measurements, so repeated measurements and, when necessary, the use of both optical and ultrasound biometry are recommended. Finally, surgical timing should often be earlier than in routine cases, particularly when cataract interferes with monitoring of retinal or glaucomatous disease.
Intraocular lens (IOL) power calculation is one of the most difficult aspects of managing these patients. Standard formulas tend to perform poorly in long eyes, leading to higher rates of refractive surprise. For this reason, the use of multiple modern formulas is recommended, with Barrett Universal II most commonly endorsed, alongside newer AI-based formulas such as Kane or Hill-RBF. Averaging results or comparing outputs helps improve accuracy. Even with these strategies, refractive outcomes remain less predictable than in normal eyes. Therefore, many surgeons prefer targeting mild residual myopia, which aligns with patients’ lifelong visual habits and reduces dissatisfaction associated with unexpected hyperopia. While some patients may opt for emmetropia, this requires careful discussion of trade-offs, particularly the loss of near vision. Importantly, patients should be informed preoperatively that additional refractive procedures may be necessary.
Intraoperatively, several challenges arise from the altered anatomy of highly myopic eyes. Zonular weakness is common and can compromise capsular stability, increasing the risk of IOL decentration or dislocation. Surgeons must therefore handle tissues gently and consider the use of capsular tension rings in selected cases. The enlarged capsular bag further contributes to instability and may influence IOL selection. Posterior capsule rupture is particularly concerning, as the presence of vitreous in the anterior chamber significantly increases the risk of retinal detachment; if it occurs, thorough anterior vitrectomy is essential to minimize vitreoretinal traction. Additionally, younger age in this population predisposes to rapid posterior capsule opacification, making meticulous cortical clean-up and capsule polishing especially important. In terms of IOL choice, hydrophobic acrylic lenses are preferred due to their stability and lower risk of opacification, whereas multifocal lenses are approached with caution because of reduced contrast sensitivity and the frequent coexistence of retinal pathology.
Minimising postoperative complications—especially retinal detachment—is a central concern. Preventive strategies begin before surgery with identification and, when appropriate, laser treatment of high-risk peripheral retinal lesions. During surgery, avoiding vitreous traction and managing complications promptly are key. After surgery, close follow-up is essential. A retinal examination within the first three months is recommended, followed by lifelong annual surveillance, as the risk of retinal complications persists indefinitely. Patients should also be educated about warning symptoms such as flashes, floaters, or visual field defects and advised to seek urgent care if these occur. In addition, intraocular pressure should be monitored closely, particularly in patients prone to steroid response.
Patient counselling plays a decisive role in achieving satisfactory outcomes. It is essential to explain that visual results are often limited by underlying retinal pathology and that cataract surgery aims to optimise, rather than restore, vision. Refractive outcomes are inherently less predictable, and the possibility of residual error or need for further intervention should be discussed openly. Particular attention should be paid to near vision expectations, as highly myopic patients are accustomed to good unaided near vision and may be dissatisfied if this is lost. The use of premium IOLs requires especially careful discussion, including the potential for dysphotopsia, reduced contrast sensitivity, and the impact of future retinal disease.
Summary
Cataract surgery in high myopia is best understood not as a routine procedure but as a complex refractive and retinal intervention. Success depends on meticulous preoperative assessment, thoughtful selection of IOL calculation strategies, careful intraoperative technique, proactive prevention of complications, and clear, realistic patient counselling.
About Prof. Grzybowski
Prof. Grzybowski is Professor of Ophthalmology at the University of Warmia and Mazury, Olsztyn, Poland, and Head of the Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan, Poland. He is an internationally recognized expert in ophthalmology and artificial intelligence, with active roles in leading scientific societies, including serving as President of the European Vision and Eye Research Association (EVER, 2023–2024) and as a lifelong member and Treasurer of the European Academy of Ophthalmology.
Prof. Grzybowski is also the founder of the AI in Ophthalmology Society, a member of Academia Europaea, and has held positions within Euretina, ESCRS, ISRS, and other international organizations. He has received numerous awards and recognitions, most recently being named several times in The Ophthalmologist’s prestigious Power List, including the 2026 list, recognising his global influence and impact on the field of ophthalmology. His latest book, Artificial Intelligence in Ophthalmology, reviews current and emerging applications of AI in ophthalmic healthcare, co-authored by world-leading experts in the field.
Widely recognized as a global authority in ophthalmology, Professor Grzybowski is ranked by Expertscape as No. 1 worldwide in both cataracts and cataract extraction, and No. 3 in endophthalmitis. His distinguished career is further marked by the 2021 ISRS Founders’ Award, honoring his exceptional contributions to refractive surgery and clinical excellence
Disclosures: Prof. Grzybowski has nothing to disclose in relation to this article. No fees or funding were associated with this article.
Citation: Expert Pearls: Cataract surgery in patients with high myopia. touchOPHTHALMOLOGY.com. 14 April 2026.
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