Phakic intraocular lens implantation (IOLs) and clear lens extraction for high to extreme myopia have grown in popularity recently as a consequence of potentially unsatisfactory results with corneal refractive surgery in higher ranges of refractive errors. The refractive outcome of these alternative modalities has been encouraging to date, yet the potential for significant complications exists. Current evidence shows that the risk of retinal detachment after clear lens extraction for myopes is high. Trials with angle-supported phakic IOLs revealed unacceptable rates of pupillary ovalization, IOL rotation, and endothelial cell loss. Iris-fixated and posterior chamber phakic IOLs have proven sufficient safety, but long-term follow-ups of current cohorts are still to be awaited. The implantation of either of the latter two phakic IOLs followed by laser in situ keratomileusis or photorefractive keratectomy (bioptics) provides another option in refractive surgery for high ametropia.