Cataract surgery in highly hyperopic eyes with short axial lengths and significant corneal astigmatism is technically demanding. The shallower anterior chamber increases the risk of iris prolapse, capsular tears, and zonular stress. Low-flow phaco settings, careful wound construction, and controlled hydrodissection are essential to maintain chamber stability and protect intraocular structures. These eyes often require high-plus IOLs, but manufacturers offer limited toric options above +30.0 D, making it difficult to correct large amounts of corneal astigmatism solely with a toric implant. When toric powers are insufficient or unavailable at high diopters, surgeons may need to perform limbal relaxing incisions (LRIs) or femtosecond laser arcuate incisions to manage residual cylinder but in this case the patient has 2.5 to 3.0 diopters of corneal astigmatism and that is beyond the capabilities of corneal incisions. For this case the calculations call for a +35.0 diopter IOL (spherical power) for a post-op prediction of emmetropia however the highest power toric IOL from this manufacturer is +34.0 diopters. IOL insertion can also be more difficult due to the small capsular bag; careful folding and slow delivery reduce the risk of zonular stress. Rotational stability is especially critical, as even minor misalignments in short eyes with steep corneas can lead to significant residual astigmatism. Complete viscoelastic removal from behind the optic and around the haptics helps prevent rotation. These cases require careful planning and a flexible intraoperative strategy to achieve optimal refractive outcomes when high-plus toric IOL options are limited or unavailable.
