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We present a case involving a patient with acute keratoconus, ocular albinism, glaucoma (C/D OD 9/10, OS 9.9/10), an almost mature cataract, and horizontal nystagmus. Surgery was challenging due to a thin iris, poor dilation, and a “pushing” eye. Despite these difficulties, combined penetrating keratoplasty and phaco on OS improved VA from counting fingers to 0.06, showcasing intricate techniques.