To evaluate the visualization performance of different approaches, including the 3D Visualization system with coaxial illumination and the 3D system or microscope with standard illumination. Fuzhou Ophthalmic Hospital, Fuzhou City, China. Cross-sectional study. This two-part performance assessment for visualization comprised of an objective analysis utilizing surgical video images and a subjective survey collecting feedback from surgeons. Data of each eye were obtained with 3 approaches: standard surgical microscope with standard illumination (SOM-S), 3D Visualization system with standard illumination (3D-S) and 3D Visualization system with coaxial illumination (3D-C). Totally 112 eyes (107 cases) and 6 cataract surgeons were involved. Red reflex value was markedly greater in the 3D-C approach compared with other 2 approaches (P<0.001). Compared with the SOM-S approach, red reflex increased by 55%, 57%, and 53% in the 3D-C approach corresponding to nuclear grades of II, III, and IV, respectively. In the questionnaire survey, red reflex scores were consistently significantly higher in the 3D-C approach than in the others (P<0.001). Depth of field was enhanced in both 3D approaches compared with the SOM-S approach (P<0.05). The only minor advantage of the SOM system over the 3D-C approach was in the surrounding field clarity score, and the difference was not statistically significant (P=1.000). The 3D-C approach significantly increased the red reflex in both objective and subjective assessments. Surgeons' responses also showed a superior performance for the 3D-C approach.