Managing Myopic Glaucoma-Beyond Structural Fragility and Diagnostic Challenges: Review Article.

Aims and background: Myopic glaucoma is a distinct subtype of glaucomatous optic neuropathy that is often underrecognized or misdiagnosed, particularly in younger patients whose intraocular pressures (IOP) fall within statistically normal ranges. High myopia presents complex structural, functional, and biomechanical challenges that hinder both early detection and effective disease management.This review summarizes current evidence on the pathophysiology, clinical presentation, diagnostic limitations, and tailored therapeutic strategies for myopic glaucoma, providing a practical clinical framework for improved management. Materials and methods: This narrative review synthesizes current evidence from peer-reviewed clinical and basic science studies on myopic glaucoma. Drawing on a comprehensive literature search, it addresses the pathophysiology, clinical presentation, diagnostic limitations, and tailored therapeutic strategies for myopic glaucoma, with the aim of establishing a clinically relevant framework to inform optimized management. Results: The global prevalence of myopia is increasing, with high myopia substantially elevating the risk of glaucoma, particularly among Asian populations. Structural alterations-including axial elongation, scleral thinning, lamina cribrosa deformation, and optic nerve head tilting-augment biomechanical vulnerability to glaucomatous damage, even when IOP remains within normal limits.Myopic glaucoma is often characterized by tilted optic discs, peripapillary atrophy, and early paracentral visual field defects, which may not be detected by standard perimetric methods. Diagnosis is complicated by the limitations of optical coherence tomography (OCT), including segmentation errors and the lack of normative databases specific to myopic eyes. Moreover, disease progression may occur even with low IOP, and distinguishing glaucomatous damage from myopia-induced structural changes remains a significant challenge. Recent advances, such as the identification of the crescent moon sign, implementation of 10-2 visual field testing, and use of biomechanically compensated tonometry, have improved diagnostic accuracy.Management requires lower IOP targets due to increased structural fragility, often necessitating combined medical therapy or early surgical intervention. However, surgery in young highly myopic patients carries a heightened risk of hypotony maculopathy.Emerging technologies, including artificial intelligence (AI)-based algorithms and widefield optical coherence tomography angiography (WF-OCTA), enhance diagnostic precision by addressing anatomical distortions and facilitating the early detection of glaucomatous changes. Conclusion and clinical significance: Early identification and tailored management of myopic glaucoma are crucial to mitigate vision loss in this high-risk population. Awareness of the unique challenges posed by high myopia, combined with emerging diagnostic and therapeutic approaches, can improve patient outcome and reduce the burden of undiagnosed disease. How to cite this article: Diniz CK, Meira MA, Gondim LAVAS,