1473

REVIEW/UPDATE

Efficacy and complications of cataract

surgery in high myopia
Yunqian Yao, BSc, Qiang Lu, BSc, Ling Wei, BSc, Kaiwen Cheng, BSc, Yi Lu, MD, Xiangjia Zhu, MD

To evaluate the efficacy and complications of cataract surgery in high and transient intraocular pressure elevation (28.15%, 95% CI,
Downloaded from http://journals.lww.com/jcrs by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 12/16/2021

myopia, a comprehensive search query was conducted from Jan-
uary 2000 to August 2020. A total of 19 586 highly myopic eyes from
28 studies were included. Modern cataract surgery turns out effica-
cious in highly myopic eyes with significant improvement of visual
acuity. However, phacoemulsification-related complications such as
posterior capsular rupture (3.91%, 95% CI, 1.98%-6.37%), retinal
detachment (1.74%, 95% CI, 1.36%-2.15%), progressed myopic
traction maculopathy (5.07%, 95% CI, 1.80%-9.37%), capsular
contraction syndrome (2.1%), intraocular lens dislocation (0.58%),
20.29%-36.70%) occurred more frequently in the highly myopic
population. Separate analyses were also conducted based on
follow-up period. In conclusion, modern cataract surgery was effec-
tive for highly myopic cataract patients, whereas careful precautions
and sufficient follow-ups were of great value because of higher
incidences of intraoperative and postoperative complications.
J Cataract Refract Surg 2021; 47:1473–1480 Copyright © 2021 Published
by Wolters Kluwer on behalf of ASCRS and ESCRS

H
igh myopia, defined as an axial length (AL) more
than 25.0 or 26.0 mm, is increasingly prevalent
across the globe and estimated to affect nearly 1
billion people by 2050.1–3 According to previous studies,
patients with high myopia are in higher risks for posterior
capsular rupture (PCR), retinal detachment (RD), macul-
opathy, posterior capsular opacification (PCO), capsular
contraction syndrome (CCS), and transient intraocular
pressure (IOP) elevation during or after cataract
surgery.3–13 Although modern phacoemulsification tech-
nique has dramatically improved the safety and outcome of
cataract surgery, these concurrent oculopathy could pos-
sibly bring uncertainties to this surgery in highly myopic
eyes. The requirement of subsequent treatment of com-
plications will also place a considerable financial burden on
individuals and on healthcare systems, which will un-
doubtedly exacerbate in the following years with the high
prevalence of high myopia.14
Although the efficacies and complications of cataract
surgery in highly myopic eyes have been widely investigated
in recent days, there was a lack of an overall estimate of
incidence rate of these complications. In this study, we took
the lead to evaluate the improvement of visual acuity and
complications of phacoemulsification in highly myopic
eyes with systematic review and meta-analysis. The risk
estimated and their influential factors summarized in this
study may help clinicians provide prognosis and precau-
tions concerning postoperative complications to highly
myopic patients.
METHODS
This systematic review adhered to the Cochrane Collaboration for
systematic reviews of intervention and is reported according to the
PRISMA guidelines.15 An extensive literature search in Ovid
Embase, Ovid Medline, the Cochrane Library at the Central
Register of Controlled Trials, ClinicalTrials.gov (www.clinical-
trials.gov), and World Health Organization International Clinical
Trials Registry Platform was conducted based on the search terms
phacoemulsification and high myopia. Complete search strategies
are provided in Supplementary Material 1 (available at http://
links.lww.com/JRS/A356). Two reviewers (Y.Y. and Q.L.) in-
dependently searched for relevant publications from January 2000
to August 2020 with restriction on English language and human
subjects. References of relevant articles were manually screened to
identify any additional studies for inclusion. Duplicate articles
were removed.
Articles were included if the following criteria were all satisfied:
(1) high myopia was defined as eyes with AL greater than
25.0 mm; (2) phacoemulsification was performed with intraocular

Submitted: January 21, 2021 | Final revision submitted: March 16, 2021 | Accepted: March 20, 2021
From the Eye Institute and Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Myopia (Fudan University); Key
Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.
Y. Yao and Q. Lu contributed equally to this work.
Supported by research grants from the National Natural Science Foundation of China (Nos. 81870642, 81470613, and 81970780), Shanghai High Myopia Study,
Science and Technology Innovation Action Plan of Shanghai Science and Technology Commission (No. 19441900700), National Key R&D Program of China (No.
2018YFC0116800), Clinical Research Plan of Shanghai Shenkang Hospital Development Center (No. SHDC12019X08 and SHDC2020CR4078), WIT120 Research
Project of Shanghai (No. 2018ZHYL0220), and the Shanghai Talent Development Fund (Grant No. 201604).
Corresponding author: Xiangjia Zhu, MD, Department of Ophthalmology, Eye and Ear, Nose, and Throat Hospital of Fudan University, 83 Fenyang Rd, Shanghai 200031,
China. Email: zhuxiangjia1982@126.com.

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1474 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA

lenses (IOLs) implantation except for occasional cases; (3) at least

one of the following items was reported: preoperative and post-
operative corrected distance visual acuity (CDVA), incidence of
PCR or RD, progression of myopic traction maculopathy (MTM,
defined as a series of complications including vitreomacular
traction, retinoschisis, macular hole, epiretinal membrane [ERM],
and foveal RD), cystoid macular edema (CME), PCO, CCS, IOL
dislocation, and transient IOP elevation (defined as postoperative
IOP ≥25 mm Hg or an elevation of IOP ≥8 mm Hg from baseline
occurring within 1 week after phacoemulsification); and (4) full-
text availablility.16
Articles were excluded if they met any of the following criteria:
(1) case reports or small case series with 3 subjects or less; (2)
phacoemulsification performed for refractive lens exchange; (3)
complex cataract surgery combined with other types of surgery;
and (4) unavailable conference studies or unextractable data.

Quality Assessment and Data Extraction

Two reviewers (Y.Y. and Q.L.) independently evaluated the quality
of the included studies according to the Methodological Index for
Nonrandomized Studies checklist, whose maximum score was 16
for noncomparative study enrolled in this study.17 Data were also
extracted independently by 2 reviewers (Y.Y. and Q.L.) using a
standardized collection form, and any inconsistencies were re-
solved by a third reviewer (X.Z.). The following data were col-
lected: (1) characteristics of studies (research design, publication
year, and regions), (2) characteristics of eyes/patients (age, sex, AL,
and follow-up period), (3) details of surgical intervention, and (4)
clinical outcomes including visual acuity and the incidence of
above-mentioned complications.

Statistical Analysis
The meta-analysis was performed using R software (v. 3.6.3).
CDVA (logMAR) was analyzed as continuous variable by com-
puting a mean difference between postoperative and preoperative
values. Pooled incidences of complications with 95% CI were
calculated. Of note, Freeman-Tukey double arcsine trans-
formation of original data were adopted when analyzing the in-
cidences of all complications, for it could deal with binary data
with low or zero incidences and stabilize the variance.18,19
Statistical heterogeneity was evaluated using the Q test and I2 Figure 1. Flow diagram outlining the selection process of systematic
statistic. When I2 was more than 50% and P value (for Q test) less review on phacoemulsification in patients with high myopia. CCS =
than 0.1, the random effects model was used; otherwise, the fixed- capsular contraction syndrome; CENTRAL = Cochrane Central
effect model was used. Meta-regression was used to detect the Register of Controlled Trials; CME = cystoid macular edema; ECCE
sources of heterogeneity. Egger test was used for detecting pub- = extracapsular cataract extraction; ICCE = intracapsular cataract
lication bias when the meta-analysis included 10 or more stud- extraction; MTM = myopic traction maculopathy; PCR = posterior
ies.20 Sensitivity analysis was performed to evaluate the robustness capsular rupture; RD = retinal detachment; WHO ICTRP = World
of the findings by excluding each study from the pooled results. Health Organization International Clinical Trials Registry Platform

RESULTS
A total of 4859 articles were identified in the initial search.
Eventually, 28 studies reporting on 19 586 eyes were in-
cluded (Figure 1). Characteristics of all included studies are
described in Supplementary Material 2 (available at, http://
links.lww.com/JRS/A357).
Efficacy of Phacoemulsification in High Myopia
A total of 9 articles evaluated CDVA before and after
phacoemulsification in highly myopic eyes.21–29 CDVA
significantly improved from preoperative 0.96 ± 0.53
logMAR to postoperative 0.35 ± 0.39 logMAR, with a
significant improvement of 0.61 logMAR (95% CI, 0.67
to 0.54 logMAR, P < .01) (Figure 2). Improvement in
CDVA was negatively correlated with preoperative CDVA
(b = 0.3689, P < .01, R2 = 0.75) and positively correlated
with AL (b = 0.0441, P < .05, R2 = 0.45) according to the
meta-regression. The results remained robust in the sen-
sitivity analysis.
Complications of Phacoemulsification in High Myopia
PCR Eight articles reported the incidence of PCR dur-
ing phacoemulsification which ranged from 1.8% to
15.6%.4,5,23,25,26,30–32 Pooled incidence of PCR was 3.91%
(95% CI, 1.98%-6.37%) (Figure 3). Meta-regression sug-
gested that incidence of PCR was inversely correlated with
AL (b = 0.0206, P < .01, R2 = 1) and publication year
(b = 0.0140, P < .01, R2 = 0.76). Sensitivity analysis
showed that the combined PCR occurrence was robust.
Retinal Detachment Sixteen articles reported the incidence
of RD in highly myopic eyes after phacoemulsification,
which ranged from 0% to 4.26%.10,23–28,30,32–39 In aggregate,
RD incidence was 1.39% (95% CI, 0.84%-2.05%), with a

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 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA
mean follow-up duration of 41.9 months (range 8.44 to
127 months). Separate analyses were made based on follow-
up time, with pooled RD incidences at 6 months, 1 year, and
3 years after phacoemulsification being 0.16% (95% CI,
0.03%-0.36%), 0.48% (95% CI, 0.01%-1.34%), and 1.12%
(95% CI, 0.26%-2.43%), respectively. Sensitivity analysis
showed that a database study by Petousis et al. significantly
contributed to heterogeneity.38 After removing the study by
Petousis et al., the overall RD incidence was 1.74% (95% CI,
1.36%-2.15%), and pooled incidences at 6 months, 1 year,
and 3 years postoperatively were 0.33% (95% CI, 0.10%-
0.64%), 0.57% (95% CI, 0.23%-1.00%), and 1.37% (95% CI,
0.88%-1.94%), respectively (Figure 4).38 No statistically
significant difference was identified between AL subgroups
(25 mm ≤ AL < 28 mm 1.74% vs AL ≥ 28 mm 2.03%, P =
.488, Figure 5).23,28,30,32,36 Egger test indicated no significant
publication bias (P = .511).
Myopic Traction Maculopathy Three articles evaluated the
progression of MTM in highly myopic eyes undergoing
phacoemulsification.16,29,40 The incidence of MTM pro-
gression ranged from 0% to 15%, and the overall incidence
was 5.07% (95% CI, 1.80%-9.37%) (Figure 6, A). The mean
follow-up length was 33.2 months (range 2 to 36 months).
Cystoid Macular Edema Five studies reported the occur-
rence of CME after phacoemulsification in highly myopic
eyes.22,26,30,40,41 In aggregate, 0.56% (95% CI, 0.28%-0.91%)
of eyes had CME after cataract surgery (Figure 6, B), with a
mean follow-up duration of 18.9 months.
PCO A total of 10 articles reported the incidence of Nd:
YAG capsulotomy for posterior capsular opacification in
highly myopic eyes.10,24,26,27,30,32–36 The incidence ranged
from 1.45% to 43.21%, and the pooled incidence was
Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.
1475
Figure 2. Forest plot comparing
preoperative and postoperative
CDVA in highly myopic eyes after
phacoemulsification.
19.21% (8.10%-33.51%) with a mean follow-up duration of
41.6 months (range 7.27 to 61.5 months) (Figure 7).
Univariate meta-regression analysis indicated that Nd:YAG
capsulotomy incidence was not associated with AL (P =
.245), age (P = .160), or the follow-up duration (P = .899).
Sensitivity analysis indicated a robust combined incidence.
No significant publication bias was identified by Egger test
(P = .124).
CCS and IOL Dislocation One study reported the incidence of
capsular contraction syndrome after phacoemulsification and
IOL implantation, which was 2.1% (14/665) in highly myopic
eyes.11 Another article reported that 0.58% (2/347) of patients
with high myopia experienced IOL dislocation, with a mean
follow-up period of 7.27 months after phacoemulsification.27
IOP Elevation Two studies reported the incidence of
transient IOP elevation after phacoemulsification in patients
with high myopia.12,42 The overall incidence was 28.15%
(95% CI, 20.29%-36.70%), pooled from 27.66% (26/94)
reported by Zhu et al. and 30.77% (8/26) by Cho.12,42
DISCUSSION
This systematic review and meta-analysis provided a general
idea on visual outcome in patients with high myopia after
cataract surgery. It also generalized phacoemulsification-
related complications in highly myopic eyes including in-
traoperative PCR and postoperative RD, MTM progression,
CME, PCO, CCS, IOL dislocation, and IOP elevation.
Patients with high myopia gained an overall improve-
ment of CDVA from 0.96 ± 0.53 logMAR to 0.35 ± 0.39
logMAR after phacoemulsification. Eyes with poorer pre-
operative visual acuity and longer AL were associated with a
greater improvement of CDVA. As longer eyes are prone to
Figure 3. Forest plot showing the
overall incidence of posterior
capsular rupture during phacoe-
mulsification in highly myopic
eyes.
Volume 47 Issue 11 November 2021
1476 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA
high-density nuclear cataract and worse preoperative visual
acuity, this may explain the greater visual gains after cataract
surgery in these eyes, as reported by previous studies.43,44
Considering the greater prismatic effect of spectacles and
smaller retinal image size accompanied with higher refractive
error, visual improvement with spectacles is usually not that
satisfactory in highly myopic population.45,46 Although pha-
coemulsification and IOL implantation could lead to a change
in the plane of correction from the spectacle to the intraocular,
which induces a magnification effect of retinal images and
could, thus, increase the visual acuity further.46,47 For extremely
highly myopic patients, such benefits may be more evident.
It is noteworthy that the visual outcomes of highly
myopic eyes are not as good as that of the general pop-
ulation. According to the studies included, 63% of eyes with
AL longer than 26.0 mm and 49% to 59% of eyes with AL
longer than 30.0 mm gained postoperative CDVA greater
than 20/40, significantly lower than the 91% reported by
UK Cataract National Dataset Electronic Multicenter Audit
or the 84% by Swedish National Cataract Register in the
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Figure 4. Forest plot showing the
overall incidence of retinal de-
tachment after phacoemulsifica-
tion in highly myopic eyes. The
vertical line represents the overall
incidence of postoperative retinal
detachment in highly myopic eyes
regardless of follow-up duration,
which is 1.74%.
general population.10,23,26,30,48 According to previous
studies, preexisting myopic maculopathy and newly-onset
postoperative complications were associated with poorer
visual outcomes in highly myopic population.27,49,50
In total, 3.91% of highly myopic eyes experienced PCR
according to our study, which is significantly higher than
the overall rate of 1.92% by British national reports or 1.8%
by American Academy of Ophthalmology Preferred
Practice Pattern Guidelines in general population.48 This
was congruent with published evidence as previous studies
suggested a 1.22-fold raised incidence of PCR with 1.0 mm
increase in AL, and a British national report based on
55 567 cataract surgeries found a 1.47-fold risk of PCR
occurrence in patients with high myopia.5,51 Higher PCR
incidence in highly myopic population may be attributed to
the following: (1) zonular weakness that enhances the
forward and backward movement of lens during surgery;
(2) lack of mechanical support for lens because of vitreous
liquefaction and posterior vitreous detachment (PVD).
Besides, our results indicated a negative correlation
 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA
between AL and PCR occurrence in highly myopic eyes.
Day et al. drew a similar conclusion based on a population-
based study, where the incidence of PCR was 1.8%, 1.7%,
and 1.3% for eyes longer than 26.0 mm, 27.0 mm, and
30.0 mm, respectively.31 They ascribed the phenomenon to
the larger proportion of surgeries with extremely high
myopia performed by more experienced surgeons, which
could significantly lower the PCR incidence. Another
possible reason is that with higher degree of myopia, an
early-onset cataract may lead to cataract surgery at a rel-
atively younger age, which could prevent PCR resulting
from age-related vitreous degeneration and zonular
weakness.5,51 Furthermore, our study indicated that the rate
of PCR in highly myopic eyes decreased significantly in
more recent studies, which may result from the continuous
advancements of surgical techniques and devices.
High myopia is also a risk factor for spontaneous retinal
detachment.52,53 Patients with high myopia have a significantly
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1477
Figure 5. Forest plot showing the
overall incidence of retinal de-
tachment after phacoemulsifica-
tion in highly myopic eyes stratified
by axial length.
higher annual incidence of RD of 102 per 100 000 compared
with 5.4 to 16.5 per 100 000 in the general population.54,55 They
also showed a 20-fold lifetime risk for RD compared with
patients with emmetropia.8,56 Movement of lens capsule
during the surgery, combined with decreased density and
stability of vitreous body in high myopic eyes, resulted in
higher risk for RD in pseudophakic highly myopic eyes.57,58
Consequently, highly myopic eyes showed a 2.74- to 18.90-fold
higher risk for RD after cataract surgery than nonmyopic
eyes.57 In this meta-analysis, the incidence of RD after pha-
coemulsification was 1.74% in highly myopic population,
much higher than 0.7% in the general population.59 Cumu-
lative incidence of RD increases with a prolonged follow-up
duration, which was in accordance with previous findings
illustrating that the distribution of cases with RD could be
balanced during follow-ups.6 Of note, the study by Petousis
et al. based on local medical record database was considered
the main source of heterogeneity and, thus, removed from
Figure 6. Forest plot showing the
overall incidence of maculopathy
after phacoemulsification in highly
myopic eyes. A: The incidence of
postoperative myopic traction
syndrome progression. B: The
incidence of postoperative cys-
toid macular edema.
Volume 47 Issue 11 November 2021
1478 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA
subsequent analysis, where the RD incidence was potentially
underestimated.38 In such cases, loss of follow-ups and missing
data (regarding death or move-out) could have biased the
outcomes.
Previous studies indicated that cataract surgery could in-
duce or promote PVD, thus may also result in increased
vitreomacular traction, MTM progression, and possibly
higher incidence of macular hole and retinal detachment in
patients with high myopia theoretically.40,60,61 In this meta-
analysis, 5.07% of highly myopic eyes experienced progressed
MTM after phacoemulsification, whereas no such report of
vitreomacular interface abnormalities progression after cata-
ract surgery has been published in general population. Lai
et al. reported that 3 (15.00%) in 20 cases experienced myopic
retinoschisis progression, with a mean follow-up duration of
15.6 months after cataract surgery, whereas it occurred in 13
(7.26%) in 179 eyes during the 3-year postoperative follow-up
according to Cai et al.16,29 However, no progression of ERM,
lamellar hole, myopic retinoschisis, or vitreomacular traction
was detected after cataract surgery in the study by Ashraf et al.,
which may be ascribed to the small sample size (5 eyes), the
short-term follow-up period (2 months), and relatively shorter
AL.16,40 Although an earlier development of PVD, as fre-
quently occurs in highly myopic eyes, is related to ERM
pathogenesis and expected to reduce the CME incidence,
ERM would increase the CME rate.41,62–64 Therefore, it re-
mains unknown where the balance lies. In this study, the
overall incidence of CME was 0.56% according to the meta-
analysis, which was comparable with the 0.1% to 2.35% in-
cidence rate in general cataract population.65 This was con-
sistent with previous studies as no association has been found
between CME incidence and high myopia.40,41 Moreover, no
correlation between AL and change of macular thickness after
cataract surgery was found.66,67
As for PCO, the most common long-term complication
after cataract surgery, we reported a cumulative Nd:YAG
incidence of 19.21% in highly myopic patients, with a mean
follow-up period of 41.6 months, which was comparable
with 20.7% at 3 years postoperatively in the general pop-
ulation.68,69 Constricted by great heterogeneity among
PCO evaluation, the rate of Nd:YAG capsulotomy was
recorded in this meta-analysis as an indicator of signifi-
cantly blurred vision.70 However, the incidence of Nd:YAG
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Figure 7. Forest plot showing the
overall incidence of Nd:YAG cap-
sulotomy after phacoemulsifica-
tion in highly myopic eyes.
capsulotomy may still not be an ideal indicator of PCO
severity because of the conservative approach of surgeons
coupled with mindset of people who prefer to avoid surgical
interventions.71 This may explain why no correlation be-
tween follow-up duration and Nd:YAG incidence was
found, which was against the widely accepted concept that
PCO was a dynamic process that progressed with time.71
Besides, controversy remains as to whether PCO or Nd:
YAG incidence is associated with AL.70,72,73 Some studies
stated that there were larger capsular bags and thinner IOLs
in highly myopic eyes, leaving space for lens epithelial cells
to migrate and proliferate, thus PCO formation.73 Although
Hayashi et al. found no statistically significant difference
regarding either Nd:YAG incidence or PCO score between
eyes with and without high myopia.70 A widely accepted
guideline for PCO evaluation is in need for further studies.
High myopia is also recognized as one of the pre-
dominant risk factors for other lens capsular complications
such as CCS and relevant IOL dislocation.74,75 However,
their incidences in patients with high myopia have been
seldom reported. Zhang et al. reported CCS incidence of
2.1% in highly myopic cataract patients, significantly higher
than an incidence rate of 0.15% to 0.86% in general age-
related cataract patients.11,76 Both higher level of growth
factor and proinflammatory status in highly myopic eyes
may contribute to the proliferation of lens epithelial cells,
hence, CCS formation.75,77 Besides, high myopia is char-
acteristic with progressive zonular insufficiency. CCS and
zonular weakness form vicious cycle and could together add
to the risk for late IOL dislocation after phacoemulsification
in highly myopic eyes. As Jeon and Kim reported, the rate
of IOL dislocation was 0.58% in highly myopic patients,
which was significantly higher than that of 0.1% in general
patients.27,78
High myopia is also a risk factor for primary open-angle
glaucoma and normal-tension glaucoma.79 Recently,
Haarman et al. conducted a meta-analysis and observed an
increased risk for primary open-angle glaucoma in patients
with high myopia with an odds ratio of 2.92.55 However,
even in highly myopic candidates with normal IOP levels, a
transient IOP elevation (also known as IOP spike) in the
early postoperative period of cataract surgery could be
spotted. In this study, the pooled incidence of transient IOP
 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA
elevation was 28.15%, significantly higher than the overall
incidence of 4.10% based on a retrospective large cohort in
the general population.80 Transient IOP elevation after
cataract surgery in highly myopic eyes could be due to their
vulnerability of blood–aqueous barrier, structural alter-
ations in aqueous humor outflow system, difficulty in
complete ophthalmic viscosurgical device removal re-
garding deeper anterior segment, and higher sensitivity to
steroid, as described by previous studies.12,81,82
With high risk for progressed retinopathy, lens capsular
complications, and pronounced IOP elevation after cataract
surgery, highly myopic population are faced with less
satisfactory visual prognosis and even irreversible visual
impairment. Extra surgical intervention and frequent visits
are usually warranted, which considerably add to the
medical and economic burden for both individual patients
and healthcare system. With the continuous rise of the
estimated global prevalence of high myopia, the issue will
become increasingly challenging.
To the authors’ knowledge, this is the first study to in-
vestigate the overall efficacy and safety of modern pha-
coemulsification, especially in high myopia, with a
systematic review and meta-analysis. However, this review
has some limitations although compensations were also
made to minimize their impacts. Given that the ad-
vancement of surgical techniques in the past decades may
have a remarkable impact on the results of published lit-
erature, we merely included studies using phacoemulsifi-
cation technique published after 2000. It added to the
applicability of the results of this meta-analysis in modern
healthcare environment. Besides, this systematic review was
inevitably prone to selection bias as the data were mostly
pooled from case series and only English-language articles
were included in the analysis. Prospective comparative
studies are further expected. Location bias was minimized
through an extensive search strategy, and there was limited
evidence of geographical variance according to the stratified
incidences. In addition, lack of universal grading method
for PCO led to great divergence in the reported incidence
rate, and a combined result of Nd:YAG capsulotomy may
not ideally represent PCO severity. We expect universal
grading system for PCO to be established and prospective
large-sample clinical studies to further evaluate the PCO
occurrence in modern cataract surgery in highly myopic
population.
In conclusion, modern technique for phacoemulsifica-
tion and IOL implantation turns out efficacious in highly
myopic eyes with significant improvement of visual acuity.
Yet, phacoemulsification-related complications such as
PCR, RD, progressed maculopathy, CCS, late IOL dislo-
cation, and transient IOP elevation occurred more fre-
quently in highly myopic population. Because of the
complicated vitreomacular status, there is often a mismatch
between apparent lens density and visual acuity, resulting in
no significant improvement in visual acuity after cataract
surgeries in some cases. In consequence, it should be
evaluated and balanced whether the potential gains are
worth undertaking the high risks of the surgery. More
Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.
1479
attention and longer follow-up duration are warranted
toward these patients.
REFERENCES
1. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P,
Wong TY, Naduvilath TJ, Resnikoff S. Global prevalence of myopia and high
myopia and temporal trends from 2000 through 2050. Ophthalmology
2016;123:1036–1042
2. Zhu XJ, Zhou P, Zhang KK, Yang J, Luo Y, Lu Y. Epigenetic regulation of aA-
crystallin in high myopia-induced dark nuclear cataract. PLoS One 2013;8:
e81900
3. Fan DS, Lam DS, Li KK. Retinal complications after cataract extraction in
patients with high myopia. Ophthalmology 1999;106:688–691
4. Zare M, Javadi MA, Einollahi B, Baradaran-Rafii AR, Feizi S, Kiavash V. Risk
factors for posterior capsule rupture and vitreous loss during phacoemul-
sification. J Ophthalmic Vis Res 2009;4:208–212
5. Fesharaki H, Peyman A, Rowshandel M, Peyman M, Alizadeh P, Akhlaghi
M, Ashtari A. A comparative study of complications of cataract surgery with
phacoemulsification in eyes with high and normal axial length. Adv Biomed
Res 2012;1:67
6. Ripandelli G, Scassa C, Parisi V, Gazzaniga D, D’Amico DJ, Stirpe M.
Cataract surgery as a risk factor for retinal detachment in very highly myopic
eyes. Ophthalmology 2003;110:2355-2361
7. Wu PC, Huang HM, Yu HJ, Fang PC, Chen CT. Epidemiology of myopia.
Asia Pac J Ophthalmol (Phila) 2016;5:386–393
8. Ikuno Y. Overview of the complications of high myopia. Retina 2017;37:
2347–2351
9. Saw SM. How blinding is pathological myopia? Br J Ophthalmol 2006;90:
525–526
10. Vasavada AR, Shah A, Raj SM, Praveen MR, Shah GD. Prospective
evaluation of posterior capsule opacification in myopic eyes 4 years after
implantation of a single-piece acrylic IOL. J Cataract Refract Surg 2009;35:
1532–1539
11. Zhang K, Zhu X, Chen M, Sun X, Yang J, Zhou P, Lu Y. Elevated trans-
forming growth factor-b2 in the aqueous humor: a possible explanation for
high rate of capsular contraction syndrome in high myopia. J Ophthalmol
2016;2016:1–6
12. Zhu X, Qi J, He W, Zhang S, Zhang K, Lu Q, Lu Y. Early transient intraocular
pressure spike after cataract surgery in highly myopic cataract eyes and
associated risk factors. Br J Ophthalmol 2020;104:1137–1141
13. Lv H, Yang J, Jiang X, Liu Y, Zhang M, Wang Y, Song H, Li X. Changes of
intraocular pressure after cataract surgery in myopic and emmetropic
patients. Medicine (Baltimore) 2018;97:e12023
14. Naidoo KS, Fricke TR, Frick KD, Jong M, Naduvilath TJ, Resnikoff S,
Sankaridurg P. Potential lost productivity resulting from the global burden
of myopia: systematic review, meta-analysis, and modeling. Ophthalmology
2019;126:338–346
15. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
2009;6:e1000097
16. Cai L, Sun Z, Guo D, Fan Q, Zhu X, Yang J, Lu Y. Long-term outcomes of
patients with myopic traction maculopathy after phacoemulsification for
incident cataract. Eye (Lond) 2019;33:1423–1432
17. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Method-
ological index for non-randomized studies (minors): development and
validation of a new instrument. ANZ J Surg 2003;73:712–716
18. Barendregt JJ, Doi SA, Lee YY, Norman RE, Vos T. Meta-analysis of
prevalence. J Epidemiol Community Health 2013;67:974–978
19. Beijer U, Wolf A, Fazel S. Prevalence of tuberculosis, hepatitis C virus, and
HIV in homeless people: a systematic review and meta-analysis. Lancet
Infect Dis 2012;12:859–870
20. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch
VA. Cochrane handbook for systematic reviews of interventions. Avail-
able at: www.training.cochrane.org/handbook. Accessed September
2020
21. Wang Q, Zhao G, Wang Q, Jia W. Visual quality after AcrySof IQ ReSTOR
intraocular lens implantation in eyes with high myopia. Eur J Ophthalmol
2012;22:168–174
22. Giansanti F, Bitossi A, Giacomelli G, Virgili G, Pieretti G, Giuntoli M,
Abbruzzese G, Menchini U. Evaluation of macular thickness after uncom-
plicated cataract surgery using optical coherence tomography. Eur J
Ophthalmol 2013;23:751–756
23. Lam JKM, Chan TCY, Ng ALK, Chow VWS, Wong VWY, Jhanji V. Out-
comes of cataract operations in extreme high axial myopia. Graefes Arch
Clin Exp Ophthalmol 2016;254:1811–1817
Volume 47 Issue 11 November 2021
1480 REVIEW/UPDATE: CATARACT SURGERY IN HIGH MYOPIA
24. Cetinkaya S, Acir NO, Cetinkaya YF, Dadaci Z, Yener HI, Saglam F.
Phacoemulsification in eyes with cataract and high myopia. Arq Bras Oftal
2015;78:286–289
25. Cagatay HH, Ekinci M, Gokce G, Odabasi M, Daraman O, Yazar Z. Clinical
outcomes of phacoemulsification and intraocular lens implantation in eyes
with high myopia. Med J Bakirkoy 2015;11:13–16
26. Akar S, Gok K, Bayraktar S, Kaya V, Kucuksumer Y, Altan C, Yilmaz
OF. Phacoemulsification in high myopia. Saudi Med J 2010;31:
1141–1145
27. Jeon S, Kim HS. Clinical characteristics and outcomes of cataract surgery in
highly myopic Koreans. Korean J Ophthalmol 2011;25:84–89
28. Li CY, Chen YC, See LC, Lin KK, Lee JS. Visual outcome after cataract
surgery in extremely high axial myopia. Ann Ophthalmol 2007;39:27–35
29. Lai CC, Yeung L, Chen YP, Wang NK, Wu WC, Chen KJ, Chuang LH, Chen
TL. Macular and visual outcomes after cataract extraction for highly myopic
foveoschisis. J Cataract Refract Surg 2008;34:1152–1156
30. Zuberbuhler B, Seyedian M, Tuft S. Phacoemulsification in eyes with
extreme axial myopia. J Cataract Refract Surg 2009;35:335–340
31. Day AC, Donachie PH, Sparrow JM, Johnston RL; Royal College of
Ophthalmologists’ National Ophthalmology Database. The Royal College
of Ophthalmologists’ National Ophthalmology Database Study of cataract
surgery: report 2, relationships of axial length with ocular copathology,
preoperative visual acuity, and posterior capsule rupture. Eye (Lond) 2015;
29:1528–1537
32. Ozbek Z, Saatci AO, Durak I, Gunenc U, Kaynak S. Phacoemulsification and
intraocular lens implantation in eyes with long axial length. Ann Ophthalmol
(Skokie) 2007;39:217–221
33. Ku WC, Chuang LH, Lai CC. Cataract extraction in high myopic eyes. Chang
Gung Med J 2002;25:315–320
34. Khan IJ, Abbott J, Bhatnager AJ, Price NJ. Three-haptic intraocular lens for
myopia: early results. J Cataract Refract Surg 2010;36:1161–1166
35. Neuhann IM, Neuhann TF, Heimann H, Schmickler S, Gerl RH, Foerster MH.
Retinal detachment after phacoemulsification in high myopia: analysis of
2356 cases. J Cataract Refract Surg 2008;34:1644–1657
36. Alio JL, Ruiz-Moreno JM, Shabayek MH, Lugo FL, Abd El Rahman AM. The
risk of retinal detachment in high myopia after small incision coaxial pha-
coemulsification. Am J Ophthalmol 2007;144:93–98
37. Williams MA, McGimpsey S, Abugreen S, Chan W, Sharkey JA, Best RM,
Johnston PB. The incidence and rate of rhegmatogenous retinal detach-
ment seven years after cataract surgery in patients with high myopia. Ulster
Med J 2009;78:99–104
38. Petousis V, Sallam AA, Haynes RJ, Patel CK, Tyagi AK, Kirkpatrick JN,
Johnston RL. Risk factors for retinal detachment following cataract surgery:
the impact of posterior capsular rupture. Br J Ophthalmol 2016;100:
1461–1465
39. Szijarto Z, Schvoller M, Poto L, Kuhn F, Kovacs B. Pseudophakic retinal
detachment after phacoemulsification. Ann Ophthalmol 2007;39:134–139
40. Ashraf H, Koohestani S, Nowroozzadeh MH. Early macular changes after
phacoemulsification in eyes with high myopia. J Ophthalmic Vis Res 2018;
13:249-252
41. Chu CJ, Johnston RL, Buscombe C, Sallam AB, Mohamed Q, Yang YC.
Risk factors and incidence of macular edema after cataract surgery: a
database study of 81984 eyes. Ophthalmology 2016;123:316–323
42. Cho YK. Early intraocular pressure and anterior chamber depth changes
after phacoemulsification and intraocular lens implantation in nonglaucom-
atous eyes. Comparison of groups stratified by axial length. J Cataract
Refract Surg 2008;34:1104–1109
43. Praveen MR, Vasavada AR, Jani UD, Trivedi RH, Choudhary PK. Prevalence
of cataract type in relation to axial length in subjects with high myopia and
emmetropia in an Indian population. Am J Ophthalmol 2008;145:176–181
44. Shekhawat NS, Stock MV, Baze EF, Daly MK, Vollman DE, Lawrence MG,
Chomsky AS. Impact of first eye versus second eye cataract surgery on
visual function and quality of life. Ophthalmology 2017;124:1496–1503
45. Srinivasan B, Leung HY, Cao H, Liu S, Chen L, Fan AH. Modern phacoe-
mulsification and intraocular lens implantation (refractive lens exchange) is
safe and effective in treating high myopia. Asia Pac J Ophthalmol (Phila)
2016;5:438–444
46. Applegate RA, Howland HC. Magnification and visual acuity in refractive
surgery. Arch Ophthalmol 1993;111:1335–1342
47. Garcı́a M, González C, Pascual I, Fimia A. Magnification and visual acuity in
highly myopic phakic eyes corrected with an anterior chamber intraocular
lens versus by other methods. J Cataract Refract Surg 1996;22:1416–1422
48. The Royal College of Ophthalmologists. Cataract surgery guidelines 2010. Avail-
able at: https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2010-SCI-
069-Cataract-Surgery-Guidelines-2010-SEPTEMBER-2010-1.pdf. Accessed
September 20, 2020
Volume 47 Issue 11 November 2021
Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.
49. Tsai CY, Chang TJ, Kuo LL, Chou P, Woung LC. Visual outcomes and
associated risk factors of cataract surgeries in highly myopic Taiwanese.
Ophthalmologica 2008;222:130–135
50. Konstantopoulos A, Yadegarfar G, Madhusudhana K, Canning C, Luff A,
Anderson D, Hossain P. Prognostic factors that determine visual outcome
following cataract surgery complicated by vitreous loss. Eur J Ophthalmol
2009;19:247–253
51. Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Asaria
RH, Galloway P, Sparrow JM. The Cataract National Dataset electronic
multicentre audit of 55,567 operations: risk stratification for posterior
capsule rupture and vitreous loss. Eye 2009;23:31–37
52. Daien V, Le Pape A, Heve D, Carriere I, Villain M. Incidence, risk factors, and
impact of age on retinal detachment after cataract surgery in France: a
national population study. Ophthalmology 2015;122:2179–2185
53. Polkinghorne PJ, Craig JP. Northern New Zealand Rhegmatogenous
Retinal Detachment Study: epidemiology and risk factors. Clin Exp Oph-
thalmol 2004;32:159–163
54. Burton TC. The influence of refractive error and lattice degeneration on the
incidence of retinal detachment. Trans Am Ophthalmol Soc 1989;87:
143–155
55. Haarman AEG, Enthoven CA, Tideman JWL, Tedja MS, Verhoeven VJM,
Klaver CCW. The complications of myopia: a review and meta-analysis.
Invest Ophthalmol Vis Sci 2020;61:49
56. Pierro L, Camesasca FI, Mischi M, Brancato R. Peripheral retinal changes
and axial myopia. Retina 1992;12:12–17
57. Qureshi MH, Steel DHW. Retinal detachment following cataract
phacoemulsification-a review of the literature. Eye (Lond) 2020;34:616–631
58. Hikichi T. Time course of development of posterior vitreous detachments
after phacoemulsification surgery. Ophthalmology 2012;119:2102–2107
59. Powe NR, Schein OD, Gieser SC, Tielsch JM, Luthra R, Javitt J, Steinberg
EP. Synthesis of the literature on visual acuity and complications following
cataract extraction with intraocular lens implantation. Cataract Patient
Outcome Research Team. Arch Ophthalmol 1994;112:239–252
60. Hilford D, Hilford M, Mathew A, Polkinghorne PJ. Posterior vitreous de-
tachment following cataract surgery. Eye (Lond) 2009;23:1388–1392
61. Mirshahi A, Höhn F, Lorenz K, Hattenbach LO. Incidence of posterior
vitreous detachment after cataract surgery. J Cataract Refract Surg
2009;35:987–991
62. Hayashi K, Manabe SI, Hirata A, Yoshimura K. Posterior vitreous detach-
ment in highly myopic patients. Invest Ophthalmol Vis Sci 2020;61:33
63. Ophir A, Martinez MR. Epiretinal membranes and incomplete posterior
vitreous detachment in diabetic macular edema, detected by spectral-
domain optical coherence tomography. Invest Ophthalmol Vis Sci 2011;
52:6414–6420
64. Gulkilik G, Kocabora S, Taskapili M, Engin G. Cystoid macular edema after
phacoemulsification: risk factors and effect on visual acuity. Can J Oph-
thalmol 2006;41:699–703
65. Zur D, Loewenstein A. Postsurgical cystoid macular edema. Dev Ophthal-
mol 2017;58:178–190
66. Gharbiya M, Cruciani F, Cuozzo G, Parisi F, Russo P, Abdolrahimzadeh S.
Macular thickness changes evaluated with spectral domain optical co-
herence tomography after uncomplicated phacoemulsification. Eye
(Lond) 2013;27:605–611
67. Wang Y, Du J, Yang M, Xu Y, Guan H, Wu J. Distinct macular thickness
changes after femtosecond laser-assisted cataract surgery of age-related
cataract and myopia with cataract. Sci Rep 2018;8:3279
68. Shaheen MS, AbouSamra A, Helaly HA, Said A, Elmassry A. Comparison
between refractive outcomes of femtosecond laser-assisted cataract sur-
gery and standard phacoemulsification. BMC Ophthalmol 2020;20:1
69. Schaumberg DA, Dana MR, Christen WG, Glynn RJ. A systematic overview
of the incidence of posterior capsule opacification. Ophthalmology 1998;
105:1213–1221
70. Hayashi K, Yoshida M, Hayashi H. Posterior capsule opacification in myopic
eyes. J Cataract Refract Surg 2006;32:634–638
71.–82. References 71–82 are listed in Supplemental Data file 1 (http://links.-
lww.com/JRS/A383)
Disclosures: None reported.
First author:
Yunqian Yao, BSc
Eye Institute and Department of Ophthalmology, Eye & ENT
Hospital, Fudan University, Shanghai, China