Background <p>The complication rate of cataract surgery in eyes with a short axial length has previously been reported as being high, however previously published studies have had small participant numbers. The aim of the study was to determine the complication rate of cataract surgery in a large cohort of eyes of axial length &lt;20.5 mm undertaken at a tertiary university hospital.</p> Methods <p>All adult eyes with axial length &lt;20.5 mm having had cataract surgery between 2001 and 2020 at the Norfolk and Norwich University Hospital were identified retrospectively. The medical records of the patients meeting the study criteria were accessed to determine complication rates.</p> Results <p>Three hundred and sixty-eight consecutive eyes with axial length &lt;20.5 mm were identified. Senior surgeons operated on 89% of eyes and fellows or residents (with at least 3 years of operating experience) operated on 11% of eyes. Intraoperative complications occurred in 4.3% of eyes and the majority of these complications were iris prolapse or iris trauma. Posterior capsule rupture occurred in 0.54% of eyes. There was a slightly higher complication rate for fellows and residents compared with senior surgeons, but this was not statistically significant (<i>p</i> = 0.4). Postoperative complications occurred in 8.2% of eyes.</p> Conclusions <p>Cataract surgery in small eyes can be undertaken safely and with comparatively low complication rates. Cataract surgery carried out by experienced surgeons and their ability to adapt surgical technique to the challenges of eyes with short axial length are fundamental factors to achieving low complication rates.</p>