The dense clouding of the lens in the nucleus leads to a cataract. Hard cataract and lens opacity gets measured and classified for better surgical outcomes. This study primarily uses SS-ASOCT to quantify nuclear opacity. The study also aimed to evaluate LOCS-III and surgical parameters. The secondary aim of this study is to assess diagnostic performance in hard nuclear cataract patients.

The cross-sectional study had 1222 cataract surgery eligible patient eyes. High-resolution lens images were taken using the latest SS-ASOCT or CASIA-2 testing device. A custom image software helped to measure average and maximum nuclear density (AND and MND). The AND/MND association with visual acuity, LOCS-III scoring, and surgical parameters was done using Spearman’s correlation analysis. The subjects got randomly split into training and validating datasets in a 9:1 ratio. The hard nuclear cataract was classified by constructing calibration curves and receiver operating characteristic curves.

SS-ASOCT images of AND and MND had significant nuclear color scores correlation with P<0.001 and R-values of 0.716 and 0.660, respectively. Their nuclear opalescence scores had R-values of 0.712 and 0.655. The AND had the largest Spearman’s values for total ultrasonic time, pre-operative corrected distance visual acuity, and cumulative dissipated energy. Nuclear density classified hard cataract with good performance for AND and MND.

The lens’s nuclear density was objectively and quantitatively assessed. The SS-ASOCT images can assure diagnostic accuracy of hard nuclear cataracts.