This article was originally published in a sponsored newsletter.

Myopes and, more specifically, high myopes who present with retinal detachments pose a unique set of challenges to vitreoretinal (VR) surgeons. Both instrumentation and surgical technique may require modification to address these cases. With the rise in myopia prevalence worldwide, there will be an associated rise in myopic retinal detachments that VR surgeons must be well-equipped to address.¹

Standard vitrectors—used to extract small pieces of vitreous—and forceps used in vitrectomy surgery have fixed lengths, with 23-gauge instruments that are typically longer than 25- and 27-gauge instruments. However, long eyes may exceed the reach of even the longest standard 23-gauge instruments. Specialty myopia forceps exist, but they may need to be requested far in advance of cases, depending on the surgery center.

With extremely high axial myopia in the absence of specialty forceps, VR surgeons may need to modify their pars plana vitrectomy technique by removing a cannula. In extreme circumstances, they may also need to decrease the intraocular pressure and press inward on the sclera with a finger while operating to reach the macula for membrane peels or to reach adjacent to the optic nerve and initiate a posterior vitreous detachment (PVD).

Unlike older patients who present for retinal detachments initiated by the onset of a PVD, high myopes tend to be younger at presentation and lack a PVD.² Therefore, the decision to proceed with vitrectomy must be weighed against the risks of intraoperative PVD induction in young patients who tend to have more adherent vitreous that increases risk of iatrogenic retinal tears and macular hole formation.

These risks most commonly lead surgeons to opt for scleral buckles in young myopes. Depending on the retinal pathology and the buckle required, buckling may further increase axial length. Additionally, buckling requires either multiple scleral suture passes or the formation of scleral belt loops—both of which add risk of scleral perforation in the thin sclera of high myopes.

Visualization is also a challenge, particularly in pathologic myopes in whom chorioretinal atrophy and extremely thin retina increase risks associated with membrane peeling. The use of triamcinolone as well as chromovitrectomy—or the use of vital dyes to assist in highlighting semitransparent tissues in the eye—greatly facilitate membrane peeling in these cases.

Lastly, myopes are more likely to have peripheral retinal pathology than non-myopes.³ It is not uncommon to see multiple tears in a high myope presenting for retinal detachment repair. These tears result in a greater risk of subtle or even indiscernible retinal breaks at the time of surgery, which may lead to a recurrent retinal detachment. For this reason, many practitioners opt for 360° of peripheral laser in cases of high myopes. However, excessive laser may limit options for retinal reattachment in the future if a recurrence of retinal detachment occurs. It also has the potential to increase postoperative inflammation and its sequelae.

VR surgeons must be diligent in operative planning and management of highly myopic retinal detachments. For patients and referring practitioners, early presentation is best to avoid progression of tears and retinal detachments. Additional research is underway to investigate possible methods of early risk detection and prevention, though the current standard of care is watchful waiting. Patients who have new symptoms of flashes of light or floaters should present promptly to an optometrist or ophthalmologist for a thorough scleral depressed exam.

1. Bullimore MA, Ritchey ER, Shah S, Leveziel N, Bourne RRA, Flitcroft DI. The Risks and Benefits of Myopia Control. Ophthalmology. 2021 Nov;128:1561-1579.

2. Ludwig CA, Shields RA, Chen TA, et al. A novel classification of high myopia into anterior and posterior pathologic subtypes. Graefes Arch Clin Exp Ophthalmol. 2018 Oct;256:1847-1856.

3. Karlin DB, Curtin BJ. Peripheral chorioretinal lesions and axial length of the myopic eye. Am J Ophthalmol. 1976 May;81:625-635.