Managing Long or Short Axial Length in Cataract Surgery

Managing eyes at the extremes of axial length (AL)—longer than 26 mm or shorter than 20 mm—presents unique anatomical and surgical challenges during phacoemulsification. This article summarizes key considerations for biometry and intraocular lens (IOL) calculations, chamber stability, and the selection of minimally invasive glaucoma surgery (MIGS) procedures in these complex cases.

By
Lauren S. Blieden, MD
January 1, 2026
9 min

Glaucoma Physician

At a Glance

Category	Detail
Condition	Cataract Surgery in Eyes with Extreme Axial Lengths
Key Mechanisms	Dynamic relationship between iris, lens-capsule complex, and hyaloid face; aqueous misdirection; posterior pupillary block.
Target Population	Patients with axial lengths longer than 26 mm or shorter than 20 mm.
Care Setting	Ophthalmic surgical settings.

Key Highlights

Unique challenges in biometry and IOL calculations for extreme axial lengths.
Increased risk of complications such as aqueous misdirection and posterior pupillary block.
Specialized IOL formulas and adjustments are necessary for accurate power calculations.
MIGS procedures can be integrated during phacoemulsification in longer eyes.
Short eyes require careful management to avoid myopic surprises and complications.

Guideline-Based Recommendations

Diagnosis

Assess axial length and anterior chamber stability preoperatively.
Monitor for signs of aqueous misdirection and posterior pupillary block.

Management

Utilize appropriate IOL formulas such as Koch/Wang and Holladay 1 for long eyes.
Consider atropinization and YAG laser treatment for postoperative aqueous misdirection.

Monitoring & Follow-up

Perform dilated exams at 1, 6, and 12 months postoperatively, then annually.

Risks

Higher risk of retinal detachment in longer eyes.
Potential for myopic surprises and complications in shorter eyes.

Patient & Prescribing Data

Patients with cataracts and extreme axial lengths.

Use high-power IOLs for short eyes and consider MIGS options for long eyes.

Clinical Best Practices

Maintain a stable anterior chamber during surgery.
Prepare for potential complications with adequate surgical tools and techniques.
Use viscoadaptive OVDs to manage fluidics effectively.