Abstract
PURPOSE: This review aims to consolidate current knowledge on the role of perforating scleral vessels (PSVs) in high myopia (HM), providing an updated overview of their clinical significance, imaging characteristics, and potential therapeutic implications. METHODS: Literature review up to July 2025. RESULTS: PSVs, originating from the short posterior ciliary arteries, penetrate the sclera and may contribute to biomechanical stress, ischemic alterations, and neovascular proliferation in highly myopic eyes. Increasing evidence suggests their complex role in the development and progression of myopic maculopathy, particularly in lacquer cracks, myopic choroidal neovascularizations, chorioretinal atrophy, and focal scleral ectasia. Advanced imaging techniques, such as enhanced depth imaging optical coherence tomography and swept-source OCT, have enabled better visualization of PSVs and their anatomical relationship with structural changes in highly myopic eyes. However, recent studies have revealed contradictory findings regarding PSVs' role in myopic choroidal neovascularization pathogenesis, with some studies suggesting a pathogenic association while others propose a protective effect. The relationship between PSVs and myopic choroidal neovascularization appears complex and context-dependent, potentially involving both mechanical stress mechanisms and hemodynamic factors. CONCLUSION: Despite their increasing recognition, the precise mechanisms by which PSVs influence myopic disease remain incompletely understood. Standardized quantification methods and prospective studies are needed to clarify their complex role in disease progression and to explore novel treatment strategies.