Cataract surgery in patients with high myopia can be particularly tricky. These eyes present with anatomical and functional differences that require careful preoperative planning, intraoperative caution, and close postoperative monitoring.
In this blog post, we break down the potential problems during cataract surgery in high myopes — stage-wise — and offer practical pearls for safe and successful outcomes.
📌 Why is High Myopia Special?
High myopia is more than just a refractive error. These eyes often have:
- Long axial lengths (>26 mm)
- Stretched and thinned sclera
- Deep anterior chambers
- Large capsular bags
- Weak zonules
- Higher incidence of posterior staphyloma, lattice degeneration, and retinal detachment
🔍 Potential Problems in Cataract Surgery with High Myopia
🩺 1. Preoperative Considerations
✅ Visual Potential:
- Assess for amblyopia and myopic macular degeneration — this helps set realistic expectations.
✅ Biometry Challenges:
- Long axial lengths make IOL power calculations less accurate.
- Use third- or fourth-generation formulas (e.g. Barrett Universal II, Haigis, Olsen).
- Swept-source biometry (IOL Master 700) is preferred, especially in the presence of posterior staphyloma.
✅ Counseling:
- Warn about risk of anisometropia if only one eye is operated on.
- Discuss postoperative visual expectations, especially if there’s macular pathology.
🛠️ 2. Intraoperative Challenges
🚫 Anesthesia Risks:
- Due to long eyes, there’s a risk of globe perforation with retrobulbar anesthesia.
- Topical anesthesia is preferred.
💧 Low IOP & Deep AC:
- These eyes tend to have low scleral rigidity and a deeper anterior chamber.
- Makes manual expression difficult (in ECCE) and phacoemulsification trickier due to deeper working space.
⚠️ Posterior Capsular Rupture (PCR):
- Increased risk due to:
- Floppy posterior capsule
- Large capsular bag
- Weak zonules
- Avoid putting downward stress with instruments at the angle.
🌪️ Surge and LIDRS Risk:
- Higher chance of Intraoperative Floppy Iris Syndrome (IFIS)-like behavior and Lens-Iris Diaphragm Retropulsion Syndrome (LIDRS).
- Manage with:
- Lower bottle height
- Gentle fluidics
- Using a second instrument to lift iris during phaco
🧯 3. Postoperative Concerns
👁️ Retinal Detachment (RD):
- Most dreaded complication in high myopes.
- Occurs due to vitreoretinal traction and lattice degeneration.
- Counsel patient to report floaters, flashes, or curtain-like vision loss immediately.
🧠 Tips for Safe Surgery in High Myopes
- Use cohesive viscoelastics to maintain chamber stability
- Perform slow, controlled phaco with minimal fluidics
- Insert IOL gently; consider three-piece IOLs if zonules are weak
- Schedule retinal evaluation pre- and post-op
- Avoid sudden pressure fluctuations
- Watch closely for IOP spikes and retinal tears post-op
📚 FRCOphth Exam Pearl
“What are the risks of cataract surgery in high myopes?”
Divide your answer into preoperative, intraoperative, and postoperative phases. Always include RD, biometry issues, and zonular weakness in your differential.