Myopic and Glaucomatous Optic Neuropathy in Highly Myopic Eyes: A Practical Framework for Diagnosis, Monitoring, and Management

High myopia is increasingly prevalent and complicates glaucoma diagnosis. Axial elongation remodels the optic nerve head (ONH) and parapapillary tissues, producing structural and functional changes that mimic glaucoma-termed myopic optic neuropathy (MON). We reviewed current concepts on the MON-glaucomatous optic neuropathy (GON) spectrum and practical implications for diagnosis, monitoring, and management. A focused PubMed search targeted high/pathologic myopia, glaucoma, ONH and parapapillary anatomy, optical coherence tomography (OCT)/OCT angiography, visual fields, and progression. Major reviews, population-based studies, and longitudinal investigations were prioritized and integrated into a clinician-oriented framework. Greater myopia severity is associated with higher glaucoma risk and, in some cohorts, greater treatment burden, including surgery. Disc tilt, torsion, parapapillary atrophy, and staphyloma-related curvature complicate structural assessment and reduce reliability of single-visit OCT due to magnification and segmentation artifacts. Visual fields may be atypical, and central defects are under-sampled by standard 24-2 testing. Progression-centered strategies-combining event- and trend-based analyses and confirmation rules-distinguish MON-predominant changes from true GON or overlap and guide follow-up. In highly myopic eyes, multimodal structure-function assessment anchored on reproducible progression enhances diagnostic confidence and guides individualized intraocular pressure-lowering therapy. Standardized reporting of myopia definitions and progression criteria is recommended.