High Myopia:
Managing a Lifetime
of Retinal Risk

Myopia — short-sightedness — affects an extraordinary proportion of the population in Singapore and across East Asia. Studies consistently show that 80–90% of young adults in this region are myopic, driven by a combination of genetic predisposition and lifestyle factors including near work and reduced outdoor time. Globally, myopia is projected to affect half the world's population by 2050.

For most people, myopia is a manageable inconvenience corrected with spectacles, contact lenses, or refractive surgery. But for those with high myopia — conventionally defined as a prescription of –6.00 dioptres or more, or an axial length exceeding 26 millimetres — the condition represents something fundamentally different. The elongated eye is under chronic mechanical stress, and the structural consequences accumulate over a lifetime.

What Changes in a Highly Myopic Eye

The fundamental problem in high myopia is axial elongation — the eye is physically longer than it should be. A normal adult eye measures approximately 23–24 mm from front to back. A highly myopic eye may measure 27, 28, or even 32 mm. Every millimetre of additional length stretches the retina, choroid, and sclera over a larger area, thinning them in the process.

This thinning has consequences. The retinal periphery becomes fragile and prone to tears. The macula — the central, most important zone of the retina — is subject to mechanical distortion and compromised blood supply. The optic nerve enters the eye at an increasingly oblique angle as the eye elongates, predisposing to glaucomatous damage. And the sclera itself can develop staphylomata — outward bulging areas of thinned, weakened wall — particularly at the posterior pole.

The Complication Cascade

Myopic macular degeneration (MMD) is the most feared complication of high myopia, and the leading cause of irreversible vision loss in patients with high myopia. It progresses through recognisable stages, visible on fundus examination and OCT.

Beyond MMD, high myopia carries substantially elevated risks of:

• Retinal detachment — up to 10 times the risk of the general population; the stretched peripheral retina is prone to lattice degeneration and tears
• Myopic traction maculopathy — vitreoretinal traction causing the macula to split (foveoschisis) or develop a hole; affects approximately 7% of highly myopic eyes over time
• Glaucoma — the structural vulnerability of the optic nerve head in myopic eyes increases susceptibility
• Cataract — nuclear cataracts develop earlier and progress faster in highly myopic eyes
• Posterior staphyloma — progressive outward bulging of the posterior sclera, causing macular distortion

For Parents: Slowing Progression in Children

The most effective time to intervene in myopia is during childhood, when the eye is still growing. Once the prescription has stabilised in adulthood, the elongation has already occurred. The two most evidence-based strategies for slowing axial elongation in myopic children are:

Low-dose atropine eye drops

Nightly application of atropine 0.01% or 0.05% has been shown in multiple randomised trials (including landmark Singapore-based studies) to slow myopia progression by 50–70% compared to placebo, with minimal side effects at low doses. Treatment is typically continued from age 6–8 through adolescence, until progression stabilises. Children on atropine still require spectacle or contact lens correction; the drops slow the progression, they do not reverse existing myopia.

Orthokeratology (Ortho-K)

Overnight rigid contact lenses that temporarily reshape the cornea, allowing spectacle-free daytime vision. Beyond the refractive benefit, orthokeratology lenses reduce peripheral hyperopic defocus on the retina — the signal thought to drive axial elongation. Multiple studies show significant reductions in axial elongation compared to standard spectacles. They are suitable for motivated children from approximately age 8–10 and require careful hygiene compliance to minimise infection risk.

For Adults: Monitoring and Surveillance

For adults with established high myopia, the goal shifts from prevention to surveillance — detecting complications early, when treatment is most effective. The following monitoring programme is appropriate for most patients with high myopia (–6.00 or above):

When Treatment Is Needed

The specific treatment depends on the complication encountered:

• Peripheral retinal tears — prophylactic laser photocoagulation or cryotherapy to seal the break before it causes a detachment. Straightforward outpatient procedure.
• Retinal detachment — surgical repair (vitrectomy or scleral buckling, see retinal detachment article). Urgency depends on whether the macula is involved.
• Myopic CNV — intravitreal anti-VEGF injections (ranibizumab, bevacizumab, or aflibercept). Myopic CNV typically responds well to anti-VEGF with fewer injections needed compared to age-related macular degeneration. Early treatment is critical to prevent irreversible scarring.
• Myopic traction maculopathy / foveoschisis — vitrectomy to relieve vitreoretinal traction, sometimes combined with ILM peeling. Indicated when progressive visual loss or a full-thickness macular hole is developing.
• Cataract — phacoemulsification, with careful attention to intraocular lens selection in highly myopic eyes (biometry is more complex in long eyes).

Frequently Asked Questions

My prescription has not changed in ten years. Am I safe?

Prescription stability does not mean the eye has stopped changing. Axial length — the physical length of the eye — can continue to increase even when the measured prescription appears stable. More importantly, the degenerative changes associated with high myopia (retinal thinning, lacquer cracks, macular changes) develop independent of refraction changes. Continued specialist surveillance is important regardless of prescription stability.

Can I have LASIK if I have high myopia?

LASIK and other refractive surgeries correct the optical prescription — they do not alter the underlying axial length or reduce the retinal risks of high myopia. A successfully treated patient who no longer needs thick spectacles still has a highly myopic eye with all its associated risks and surveillance requirements. This is an important point that is sometimes not communicated clearly in the context of refractive surgery.

My child has –3.00 dioptre myopia at age 10. Should I be worried?

Early onset and rapid progression are the most important risk factors for eventually reaching high myopia. A child with –3.00 at age 10 is at meaningful risk of reaching –6.00 or beyond by adulthood without intervention. This is exactly the scenario where myopia control (atropine and/or orthokeratology) should be discussed with a specialist. The goal is to slow progression before the eye elongates to the threshold where significant complications become likely.

Is there any treatment to reduce existing axial length?

Currently, no treatment reliably reduces established axial length in adults. Scleral reinforcement surgery (posterior scleral reinforcement) has been studied for progressive high myopia in children, but it is not widely performed and evidence for long-term benefit remains limited. Research into scleral cross-linking and other structural approaches is ongoing.

At what degree of myopia should I be worried about complications?

High myopia is generally defined as a prescription of −6.00 dioptres (600 degrees) or more. However, the risk of complications increases progressively with higher prescriptions and longer eye length. If your prescription is −5.00 or above, regular dilated eye examinations and OCT scans are recommended to catch any changes early.

Can LASIK cure the risks associated with high myopia?

No. LASIK and other refractive surgeries correct the focusing error, so you can see clearly without glasses. However, they do not change the physical elongation of the eye or its structural vulnerabilities. After LASIK, you still carry the same risk of retinal detachment, macular degeneration, and other complications associated with high myopia. Regular retinal screening remains essential.

How often should someone with high myopia have their eyes checked?

At minimum, once a year with a dilated eye examination and OCT scan. If your eye doctor identifies any risk factors or early changes such as lattice degeneration, retinal thinning, or early macular changes, more frequent monitoring may be recommended. Between visits, watch for sudden floaters, flashes of light, or distortion in your vision.

Can myopia progression be stopped in children?

Current treatments can slow but not completely stop myopia progression. Options include low-dose atropine eye drops, specialised spectacle lenses, orthokeratology (overnight contact lenses), and increased outdoor time. Starting myopia control early gives the best chance of limiting the final prescription and reducing the risk of future complications.

Is high myopia hereditary?

Yes, there is a strong genetic component. If one or both parents are highly myopic, the child has a significantly higher risk of developing myopia. However, environmental factors such as prolonged near work and limited outdoor time also play an important role, particularly during childhood.