Operating on a nanophthalmic eye with a 14 mm axial length is one of the most challenging scenarios in ophthalmic surgery. These eyes are not just small; they are structurally crowded, featuring a disproportionately large lens, a shallow anterior chamber, and a thickened sclera. In these cases, you must anticipate zonulopathy and extreme anatomical crowding. Because the ciliary body is often anteriorly displaced and the anatomy is so compressed, the typical landmark of the pars plana may be virtually non-existent. This makes traditional posterior segment access or vitreous tapping extremely hazardous, as you risk hitting the retina or ciliary body. To manage the high risk of uveal effusion and malignant glaucoma, pre-placed posterior sclerotomies can be done however, without a true pars plana, these must be performed with extreme caution. In the case shown here, a CTR is placed once the nucleus is brought out of the capsular bag but then it disappears as the entire capsular bag comes out. So where is the CTR? And what will you do now? How will you secure the IOL? This case is 11/10 in difficulty!
