Introduction: High myopic astigmatism often presents a challenge for cataract surgeons. Procedures such as limbal relaxation incisions may also be impossible in the setting of an extensive refractive surgical history. Patient and Clinical Findings:A 61-year-old woman for cataract surgery with a history of automated lamellar keratoplasty, 4-incision radial keratotomy, and arcuate incisions in the left eye. Astigmatism was 8.00 diopters (D) by manifest refraction, and on optical biometry, corneal topography, and auto keratometry, astigmatism was 9.01 D, 7.52 D, and 8.25 D, respectively.Diagnosis, Intervention, and Outcomes: A primary in-thebag toric intraocular lens (IOL) and piggyback toric IOL with reverse optic capture were used. A surgically induced astigmatism of 6.59 D, magnitude of error of À1.41 D, angle of error 5.6 degrees, and correction index of 0.82 were achieved. Owing to limited potential improvement with IOL rotation, additional enhancement with photorefractive keratectomy (PRK) of À0.61 À1.78 × 69 degrees was performed to achieve desired results and high patient satisfaction. Preoperative corrected distance visual acuity was 20/50, and the uncorrected visual acuity achieved after cataract surgery and PRK enhancement was 20/25. Conclusions:The use of double toric IOLs for treating high astigmatism in patients with prior keratorefractive surgery is reported.