Objective This study aims to examine the characteristics and influencing factors of crystalline lens tilt and decentration in ultra-high myopic cataract patients, as measured by the CASIA2. Methods and Analysis 60 eyes scheduled for cataract surgery with an axial length (AL) >= 28 mm were included. The IOLMaster700 was utilized to measure AL and the white-to-white (WTW) distance. The CASIA2 was employed to measure front curvature radius (FCR), crystalline lens tilt, and crystalline lens decentration. The relationships between lens tilt, decentration, and related factors were evaluated. Results The degree of lens tilt was 4.62 +/- 2.44 degrees, and the decentration was 0.20 (Q1 0.13, Q3 0.28) mm. Among the 60 eyes, 11 (18.3%) had a tilt >= 7 degrees, and 6 (10%) had a decentratiolens tilt >= 7 degrees (P = 0.038, P = 0.018). Eyes with AL >30.00 mm and FCR <8.45 mm had a higher degree of lens tilt. Additionally, a tilt >= 7 degrees was associated with a greater decentration (P = 0.032), n. Conclusion Preoperative crystalline lenses in eyes with ultra-high myopia and cataract exhibit certain degrees of tilt and decentration. An AL >30 mm is a risk factor for a lens tilt >= 7 degrees and an decentration >= 0.4 mm. An FCR <8.45 mm is a risk factor for increased lens tilt, and a tilt >= 7 degrees is a risk factor for increased lens decentrati >= 0.4 mm. An increase in AL and FCR <8.45 mm were risk factors for a and eyes with AL >30.00 mm had a higher degree of decentration (P = 0.005).