A comprehensive preoperative systemic assessment is crucial for individuals undergoing cataract surgery, especially those with hyperopia. Hyperopic eyes are structurally more prone to complications, particularly when the anterior chamber is shallow and pseudoexfoliation syndrome (PXF) is present. These eyes are at greater risk of AC collapse during surgery, increasing the likelihood of iris prolapse and capsular rupture (33). Additionally, PXF, which is common in hyperopic eyes, heightens the risk of zonular weakness, poor pupil dilation, and intraoperative complications (34). The use of medications such as alpha-1 blockers for benign prostatic hyperplasia (BPH), which can further increase these risks by contributing to intraoperative floppy iris syndrome (IFIS). Alpha-1 adrenergic receptors are present in the iris dilator muscle. Alpha-1 blockers, such as tamsulosin, alfuzosin, doxazosin, and terazosin, inhibit these receptors, reducing the muscle’s response to vasodilatory agents. This can result in IFIS during surgery, characterized by inadequate preoperative pupil dilation, iris billowing and flaccidity, and iris prolapse into the surgical incisions. Hyperopic eyes are particularly vulnerable to anterior chamber (AC) collapse due to their shallow AC, which exacerbates IFIS. Additionally, hyperopic eyes are at an increased risk of fluctuations in intraocular pressure (IOP), further complicating surgical visualization (35, 36).

A thorough ocular assessment is essential to identify other risk factors affecting intraoperative and postoperative outcomes. Key components of this assessment include evaluating the patient’s visual potential as Hyperopia is a considerable risk factor for amblyopia in childhood due to the demands of accommodation. Identifying residual amblyopia before surgery is essential for managing postoperative expectations (37). Long-standing hyperopia might result in accommodative esotropia because to severe accommodative strain. Surgeons must consider this to avert postoperative binocular vision complications (38). A detailed anterior segment examination is essential to evaluate the cornea for transparency and curvature, utilizing topography to detect irregular astigmatism, and examining the corneal endothelium helps anticipate the risk of corneal decompensation. Hyperopic eyes with shallow ACD may present borderline conditions that increase this risk (39). Measuring the ACD, degree of pupil dilation, signs of PXF. Inadequate dilation frequently occurs in hyperopic eyes with PXF, elevating zonular tension and intraoperative difficulties (34). Type and grade of cataracts (e.g., nuclear sclerosis, cortical cataract, posterior subcapsular cataract, or polar cataract), with findings correlated to best-corrected vision.

The association between cataract grading and best-corrected visual acuity (BCVA) is conducted to assess cataract severity, hence informing surgical necessity and anticipated results (40).

The lens zonules should be assessed by evaluating pupil dilation, comparing ACD between both eyes, and examining the stability of the lens, which may reveal phacodonesis in cases of severe zonular dialysis.

Measuring intraocular pressure, examining the angle, and evaluating the optic disc is crucial, as hyperopia is a well-known risk factor for angle closure glaucoma because of shallow anterior chamber and relatively thick lens (41). A dilated fundus examination is essential to assess for choroidal folds in cases of acquired hyperopia and signs of posterior microphthalmos in high hyperopia. Additionally, macular edema should be looked for, especially in cases of acquired or induced hyperopia, such as central serous chorioretinopathy (42).

Ultrasound Biomicroscopy (UBM) is particularly valuable in assessing the integrity of the zonular apparatus when clinical signs are inconclusive or in the presence of PXF, as it allows high-resolution visualization of the ciliary body and zonules (43).

Hyperopic eyes are more susceptible to significant refractive discrepancies postoperatively (postoperative anisometropia), especially when the second eye remains untreated. During the interim between procedures, counseling involves informing patients about potential visual impairments, such as dizziness, headaches, or blurred vision. It is also important to emphasize the need for soon-to-be-performed contralateral eye surgery to restore binocular vision and reduce anisometropia (44).

Short-term management may include prescribing contact lenses for the unoperated eye to temporarily balance refractive discrepancies or using high-index spectacle lenses with low thickness to manage anisometropia. Long-term strategies involve planning early cataract surgery in the second eye to synchronize refractive outcomes and restore binocular vision or considering refractive enhancement procedures, such as LASIK or PRK, if indicated (45).

Ocular biometrics, precisely ACD, and AL are essential for accurately selecting and calculating the appropriate IOL during cataract surgery. The ACD, defined as the distance between the corneal endothelium and the anterior surface of the lens, is critical for determining the suitability of different IOL types, particularly phakic IOLs. A shallower ACD may increase the risk of complications related to specific lens types or surgical techniques and can affect IOL power calculations in advanced models. The eye’s AL, measured from the corneal surface to the retina, is crucial for precise IOL power calculation. A reduced AL in hyperopic eyes may lead to overestimating IOL power when traditional methods are used. Conversely, an extended AL in myopic eyes may underestimate IOL power without using contemporary formulas (46, 47). As mentioned earlier, selecting the appropriate IOL type is critical to ensuring optimal surgical outcomes. Precise IOL power estimation is essential in cataract surgery to attain optimal postoperative visual results. The precision of these computations has markedly improved due to technological breakthroughs and the introduction of advanced formulas. Parameters include AL, corneal power (keratometry), AC, and lens thickness are essential for ascertaining the appropriate IOL power. Contemporary models integrate these characteristics, frequently employing machine learning or ray tracing, to accommodate changes in ocular geometry, particularly in individuals with short, long, or post-refractive surgery eyes (46, 47). The selection of the appropriate formula depends on the patient’s ocular characteristics, ensuring customized and accurate outcomes for each individual as shown in Table 3.

In hyperopic patients with short AL, studies suggest that the Barrett Universal II and Holladay 2 formulas offer superior accuracy over older third-generation formulas like SRK/T and Hoffer Q. The Kane formula, which incorporates artificial intelligence-driven optimization, also demonstrates high predictive accuracy across various eye lengths, particularly in post-refractive and short eyes. The Haigis formula, which directly uses ACD values, performs well in eyes with unusual anterior chamber dimensions but may be less accurate than Barrett or Kane in high hyperopia (48–50).

In hyperopic patients who have undergone prior corneal refractive surgery (e.g., LASIK or PRK), cataract surgery presents unique challenges in both biometric assessment and IOL power calculation. These eyes often exhibit altered anterior corneal curvature, loss of the normal anterior–posterior corneal power relationship, and disrupted ELP prediction, all of which can compromise the accuracy of standard IOL formulas. In particular, traditional keratometry tends to overestimate corneal power in post-hyperopic LASIK/PRK eyes, increasing the risk of postoperative hyperopic refractive surprises (51–53). These inaccuracies are exacerbated in the absence of historical refractive data, which is often the case. To address these issues, surgeons should employ advanced technologies such as ray-tracing biometers or swept-source OCT devices, which more accurately measure total corneal power (54, 55). The use of dedicated post-refractive surgery formulas is essential in these cases; among the most validated options are the Barrett True-K (no-history), Haigis-L, Shammas-PL, and the artificial intelligence-driven Kane post-refractive formula, all of which demonstrate improved accuracy over traditional third-generation formulas. Intraoperative aberrometry may also be considered for real-time confirmation of IOL power. With respect to IOL selection, multifocal lenses are generally discouraged in these eyes due to potential corneal irregularity and reduced contrast sensitivity. Instead, monofocal or enhanced monofocal IOLs are preferred, while EDOF lenses may be cautiously considered in patients with regular topography and stable corneal surfaces. Incorporating these adjustments into preoperative planning helps mitigate refractive surprises and optimize visual outcomes in this high-risk subgroup (56–59).

Optimal patient positioning during cataract surgery is crucial, particularly for hyperopic individuals who may present anatomical challenges. Hyperopic eyes often have a shallow anterior chamber, and deep-set eyes can further complicate surgical access and visualization. Proper alignment helps mitigate these difficulties, ensuring a safer and more efficient procedure.

Head position: The angle of the headrest is adjusted by placing the patient’s head in modest extension (chin lifted) to enhance the surgeon’s approach angle and improve visualization of the anterior area. Aligning the visual axis is performed to ensure the patient’s visual axis coincides with the microscope’s center, hence minimizing parallax errors (61).

Table position: Modifying the operating table’s height to enable the surgeon to sustain an ergonomic posture while ensuring stability in the surgical field. Adjusting the table to a Trendelenburg position can, in certain instances, facilitate the deepening of the AC by utilizing gravity to displace intraocular contents posteriorly (62).

Utilization of Eye Speculum: Choosing a suitable speculum for patients with deep-set eyes to guarantee complete visibility of the surgical area while avoiding excessive strain on the globe (63).

A secondary device (e.g., chopper or cyclodialysis spatula) is employed to stabilize the globe or retract tissue, which may be essential for enhanced control (64).

Hyperopic eyes with a shallower anterior chamber and positive posterior pressure may respond less favorably to peribulbar or retrobulbar anesthesia due to increased risk of globe compression and shallow chamber collapse. Unlike emmetropic or myopic eyes, hyperopic eyes often have crowded anterior segments and a deeper orbital set, which necessitates more strategic positioning and greater care in globe stabilization during surgery.

They play a crucial role in maintaining anterior chamber stability during surgery. Dispersive viscoelastics provide corneal endothelium protection, while cohesive viscoelastics, such as sodium hyaluronate 1.4%, enhance chamber volume and deepen the anterior chamber. To maintain intraoperative stability, wound margin hydration is performed to achieve sufficient stromal hydration, preserving anterior chamber integrity (70).

Performing a well-centered and intact capsulorrhexis is a crucial step in cataract surgery. In hyperopic eyes with shallow anterior chambers, the risk of peripheral tearing increases due to limited working space, elevated intraocular pressure (IOP), and increased zonular stress. Specific techniques and instruments can mitigate these risks and improve surgical outcomes (61).

In primary angle closure/primary angle closure glaucoma, lens removal deepens the anterior chamber and widens the angle, but long-standing peripheral anterior synechiae can limit trabecular access. Combining phaco with goniosynechialysis (GSL) can mechanically strip peripheral anterior synechiae and restore outflow. Where angle tissue is accessible, trabeculotomy (e.g., ab interno techniques) may further reduce IOP and medication burden.

Hyperopic eyes with a shallow AC are at increased risk of corneal endothelial injury due to restricted working space and the close proximity of the phaco tip to the corneal endothelium. The following parameter configurations can help mitigate endothelial damage:

Iris prolapse frequently occurs in shallow anterior chambers due to elevated intraocular pressure (IOP) or improper incision formation. The following techniques help mitigate this risk: