• Users Online: 2616
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 326-329

Comparison of visual outcomes and complications of scleral-fixated intraocular lens and iris-claw lens in aphakic patients

Department of Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission01-Nov-2019
Date of Decision20-Nov-2019
Date of Acceptance03-Dec-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Vrushali Shende
Plot Number B 22/1, Besides Gandhigram College, MIDC, Wardha - 442 001, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_171_19

Rights and Permissions

Introduction: With newer advances and improved techniques for implantation of posterior chamber intraocular lens (IOLs) in cataract surgery, the chances of encountering aphakia have reduced significantly. There is still a need to study secondary IOLs to deal with cases involving no or weak capsular support. In such cases, anterior chamber IOLs (ACIOL), iris-claw lens (ICL), or scleral-fixated IOLs (SFIOL) may be used. Excluding ACIOLS by virtue of higher complication rates, this study was done to explore the superiority of SFIOL and ICL. Aim: The aim of the study is to compare the visual outcome and complications of posterior ICL and SFIOL. Materials and Methods: It was a prospective interventional hospital-based study on 26 patients from the ophthalmology outpatient department fulfilling inclusion and exclusion criteria. Detailed history and ophthalmological examination was done for all patients and they were divided into two groups based on iris morphology. Of 26 aphakic patients, 13 were implanted with ICL and 13 with SFIOL by a single surgeon, and visual activity and complication rates in both the groups were compared. Results: There was a statistically significant difference in visual acuity (VA) on day 1 postoperative with 6/18 vision on Snellen's chart in ICL-implanted patient and 6/60 in SFIOL-implanted patients. However, best-corrected VA on the 45th day postoperative was comparable in both the groups. Complication-wise SFIOL group showed dreadful complication like retinal detachment, whereas ICL group presented maximally with immediate postoperative iritis and ovalization of the pupil as long-term complication which was harmless. Conclusion: Both ICL and SFIOL are good choices for secondary IOL implantation. Visual outcomes of both the lens were comparable on late follow–up; however, complication-wise ICL is preferred over SFIOL.

Keywords: Aphakia, complications, intraocular bag weakness, secondary intraocular lens

How to cite this article:
Daigavane S, Shende V, Prasad M. Comparison of visual outcomes and complications of scleral-fixated intraocular lens and iris-claw lens in aphakic patients. J Datta Meghe Inst Med Sci Univ 2019;14:326-9

How to cite this URL:
Daigavane S, Shende V, Prasad M. Comparison of visual outcomes and complications of scleral-fixated intraocular lens and iris-claw lens in aphakic patients. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2021 Jun 15];14:326-9. Available from: http://www.journaldmims.com/text.asp?2019/14/4/326/289841

  Introduction Top

With newer advances and improved techniques for implantation of posterior chamber intraocular lens (IOLs) in cataract surgery, the chances of encountering aphakia have reduced significantly. There is still a need to study secondary IOLs to deal with cases involving no or weak capsular support. In such cases, anterior chamber IOLs (ACIOL), iris-claw lens (ICL), or scleral-fixated IOLs (SFIOL) may be used. Most surgical techniques involved in the correction of aphakia involve preventing intra- and postoperative astigmatism. ACIOLs being placed at nonphysiological location in the eye and have a high risk of endothelial cell loss, secondary glaucoma, and severe uveitis, they are least preferred nowadays.[1] Later in 1978, Worst first introduced ICL.[2] According to the position of ICL fixation, ICL is classified into anterior chamber ICL and retropupillary ICL.

  Materials and Methods Top

The technique of retropupillary iris fixation of ICL, which was first reported by Andreas Mohr in 2002, offers several advantages such as it combines the benefit of posterior chamber implants with a low-risk method of surgery and its cosmetic benefit, by hiding the IOL haptic and parts of the lens behind the iris, less surgical time, and also, preserves the anatomy of the anterior segment.[3] In the 1980s, Malbran et al. first described sutured SFIOLs for the management of aphakia following intracapsular cataract extraction[4] After a decade, in 1991, Lewis popularized the concept of ab externo suture technique.[4] With the invention of different methods of scleral fixation (SF) of IOL, today, it is convenient for ophthalmic surgeons to choose. Even though the implantation of SFIOL simulates more closely to anatomical position, it requires experienced surgeons with skillful surgical techniques and a long operative procedure. Thus, it is imperative to study in depth the real-time advantages and disadvantages of secondary IOLs and determine their safety and efficacy. The aim of this study is to compare between SFIOL and ICL in terms of visual rehabilitation and rate of complications.


The study was conducted in the Ophthalmology Department of Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha. All surgeries were conducted by a single experienced surgeon. This was a hospital-based prospective interventional study carried out for 6 months from April 2018 to September 2018. Ethical clearance was obtained from an institutional ethical clearance committee (IEC NO.-2018-19/7133). A total of 26 aphakic patients of the ophthalmology outpatient department (OPD) of Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha were participated in the study.

Inclusion criteria

  1. Patients who were left aphakic without access to adequate capsular bag support after cataract extraction surgery
  2. Patients with no other intraocular surgery history other than cataract surgery
  3. Patients who experienced an improvement in visual acuity (VA) following aphakic correction
  4. Patients with no detectable retinal pathology.

Exclusion criteria

  1. Patients aged ≤18 years
  2. Aphakic patients due to a dropped nucleus/IOL
  3. Patients who had undergone combined surgery (penetrating keratoplasty and pars plana vitrectomy)
  4. Patients who had undergone IOL exchange
  5. Patients with corneal scars
  6. Patients with glaucoma.

Sampling procedure

Patients were duly screened and evaluated in the OPD and after taking inclusion and exclusion criteria into consideration, they were admitted for the procedure and explained the details of the study. Those patients who were willing to participate in the study, written informed consent was obtained and patients were enrolled in the study.

Sample size

  • A total of 26 patients were included and divided into two groups: ICL group and SFIOL group.

Data collection tools and process

The study has adhered to the tenets of the Declaration of Helsinki, and it was approved by an Institutional Ethical Committee (IEC NO.-2018-19/7133).

  1. Data collection included patient's age, sex, and systemic and ocular medical and surgical history; preoperative VA on Snellen's vision chart and best-corrected VA (BCVA) were noted; and intraocular pressure (IOP) was measured using noncontact tonometer. Detailed slit-lamp biomicroscopy for anterior and posterior segment evaluation was done; special attention was paid on the morphology of the iris to decide whether ICL or SFIOL was to be implanted. A-scan was done. The IOL power of all the cases was calculated according to the Sanders–Retzlaff–Kraff II formula.[5] Blood pressure and random blood sugars were noted for all patients. Xylocaine sensitivity was done for all patients
  2. Patients were divided into two groups: ICL group and SFIOL group based on the condition of the iris which made putting iris claw difficult or impossible such as floppy iris, traumatic mydriasis, highly vascular iris, or preexisting iris atrophy
  3. After the surgery, VA was measured on postoperative days 1, 7, and 45 on follow-up. Slit-lamp examination was done on postoperative day 1 and follow-up to look for any complications, such as corneal edema, anterior chamber and posterior segment reaction, hypotony, striate keratopathy, IOL decentration, instability, disenclavation, pupil ovalization, cystoid macular edema, vitreous hemorrhage, and retinal detachement were noted.

Surgical procedure

Both the types of surgeries were carried out under peribulbar anesthesia.

Iris-claw lens implantation

A corneoscleral 12 O'clock frown tunnel incision of 5.5 mm was made. Two paracenteses were made at 2 O'clock and 10 O'clock for the use of Sinskey hook for the retropupillary enclavation of the ICL. The pupil was constricted using intracameral pilocarpine. A small amount of viscoelastic substance was injected from the periphery of the eye and never directly into the pupillary area as there is no barrier between the anterior and posterior segments. The optic of ICL was held with iris-claw holding forceps, one haptic was tilted down and pushed under the iris with gentle manipulation, and simultaneously, a Sinskey hook was passed through the paracentesis on the same side. Once the haptic of the IOL was behind the iris and the iris was enclaved into the haptic claw with gentle push with the Sinskey hook, the dimple at the site of enclavation was noted. A similar maneuver was done for the other haptic. Peripheral button iridectomy was done at 12 O'clock. Subconjunctival gentamicin and dexamethasone 0.5cc injection was given at the end of the procedure.

Scleral-fixated intraocular lens implantation

Ab externo technique – A corneo-scleral 12 O'clock frown tunnel incision measuring 5.5 mm was made. Sufficient peritomy was done at 3 O'clock and 9 O'clock to make scleral flaps 180° apart. A double-armed 10-0 nylon suture with a straight needle was used and railroaded through the scleral bed on one side and removed from the opposite bed with the help of 26 gauge bent needle. Then, the sutures were drawn out through the scleral tunnel and cut into two halves. Each half of the sutures was passed through the fixation eyelet on the superior and inferior haptic of the IOL at the point of maximum haptic spread.

A single piece, all polymethyl-methacrylate, large optic IOL was used in the study. The IOL was introduced into the posterior chamber, and the sutures were tightened and tied and the scleral flap was reposited over the bed and sutured with 10-0 nylon suture. The viscoelastic substance was cleared from the anterior chamber. The sclerocorneal and conjunctival peritomies were closed with 10-0 nylon sutures. Subconjunctival gentamycin and dexamethasone 0.5cc injection was given at the end of the procedure.

Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 22nd March 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/315.

  Results Top

Of 26 patients, the study included 65% (17) of the males and 35%[6] of the females. Patients in both the groups were matched for age and sex. Thirteen of 26 were implanted ICL and 13 were implanted SFIOL. A majority of patients in both the groups were in the age group of 55–70 years, the mean age being 67.33 years. Preoperatively, 38.46% of the patients had BCVA in the range of 6/18–6/6, whereas 61.5% (16) had between 6/60–6/24. On comparing VA of patients in both the groups postoperatively, it showed that in ICL group, 92.3% had gained VA postoperatively, whereas 7.7% showed no improvement. Similarly, in SFIOL group, 92.3% had gained VA after surgery, but 7.7% had shown reduction at the 45th day postoperative. The mean intraoperative time required for ICL implantation was 12.06 min which was much less than SFIOL implantation, i.e. 30.25 min. The most common immediate postoperative complication was iritis seen in both the groups. Retinal detachment was found to be a late complication in one patient with SFIOL implantation.

  Discussion Top

A comprehensive insight into the management of aphakia is of importance to ophthalmologists in this day and age so they may address it with minimum ocular morbidity to the patient. As ICL and SFIOL are the most commonly used alternatives over ACIOL in complicated cataract surgery, this study was conducted to compare which modality offers better visual outcomes and lesser complications postoperatively.

In this study, visual outcomes in ICL and SFIOL implantation are comparable to each other and greater than preoperative BCVA. Mahajan and Datti found that ICIOL and SFIOL have statistically comparable results as far as postoperative BCVA is concerned.[3] According to Kaczmarek et al., no statistically significant differences were observed in the mean presurgical BCVA between the two groups.[8] Madhivanan et al.,[7] Farrahi et al.,[5] Rashad,[10] and many more found similar results.

Most common early postoperative complication was found to be iritis in both the comparison groups; however, late complication like retinal detachment was seen only in 1 patient in SFIOL group. Farrahi et al. found that complications in the IC-ACIOL group included pigment deposition on the lens surface in three eyes which resolved spontaneously in all.[5]

Ovalization of the pupil was seen in two patients with ICL and SFIOL each. The reason for the oval pupil was different in both the groups. In the study done by Mahajan and Datti, pupil ovalization was the most common complication in ICIOL; among 5 (16.6%) patients, they observed that 3 (10%) patients had permanent ovalization as opposed to 1 in SFIOL. It can occur due to asymmetrical fixation of haptic or tight fixation. Hyphema was also observed in a single patient of the ICL group, cause being trauma to the iris while hooking the ICL.

Other reported complications with SFIOL such as endophthalmitis, IOL dislocation, suture erosion, suprachoroidal hemorrhage, and expulsive hemorrhage were not observed in our study which is in accordance with another study conducted by AL Young et al.

Postoperatively, IOP was raised in 30.7% and 38.5% in ICL and SFIOL group, respectively, only in the 1st postoperative week, which was controlled by single antiglaucoma drug. In the study conducted by Farrahi et al.,[5] complications in the SF of posterior chamber intraocular lenses group included CME in one patient, conjunctival erosion induced by the scleral sutures in one patient, and raised IOP in two patients which was also controlled by topical medications.

In the ICL group, the pupil is oval due to asymmetrical fixation of the iris in haptic, whereas in the SFIOL group, the pupil is oval either due to iris capture in suture or vitreous strands in the pupillary area. In either case, this postoperative complication is acceptable long term when its' effect on ultimate VA is considered [Figure 1], [Figure 2], [Figure 3].[9],[10],[11],[12],[13]
Figure 1: Comparison of pre and postoperative best corrected visual acuity

Click here to view
Figure 2: Pre and postoperative comparison of best corrected visual acuity

Click here to view
Figure 3: Comparison of postoperative complication

Click here to view

  Conclusion Top

ICL implantation and SFIOL implantation are physiological modalities of secondary IOL implantation in aphakic patients secondary to complicated cataract surgery. Visual outcomes of both the lens are comparable on follow–up; however, complication-wise ICL is preferred over SFIOL. Complication like pupil ovalization seen with ICL was harmless and others were treatable. Furthermore, the easy technique of ICL implantation and shorter surgical time will attract more ophthalmic surgeons toward ICL implantation and thus replace SFIOL as treatment of choice.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Jing W, Guanlu L, Qianyin Z, Shuyi L, Fengying H, Jian L, et al. Iris-claw intraocular lens and scleral-fixated posterior chamber intraocular lens implantations in correcting aphakia: A meta-analysis. Invest Ophthalmol Vis Sci 2017;58:3530-6. doi:https://doi.org/10.1167/iovs.16-21226.  Back to cited text no. 1
Worst JG. Extracapsular surgery and lens implantation. Ophthalmic Surg 1977;8:33-6.  Back to cited text no. 2
Mahajan AR, Datti NR. Comparison of Iris Claw Lens and Scleral Fixated i.pdf. Available from: http://www.jcbsonline.ac.in/Articles/Volume4_Issue4/7. ClinicalInvestigation1_V4I4.pdf. [Last accessed on 2018 Dec 7].  Back to cited text no. 3
Stem MS, Todorich B, Woodward MA, Hsu J, Wolfe JD. Scleral-fixated intraocular lenses: Past and present. J Vitreoretin Dis 2017;1:144-52.  Back to cited text no. 4
Farrahi F, Feghhi M, Haghi F, Kasiri A, Afkari A, Latifi M. Iris claw versus scleral fixation intraocular lens implantation during pars Plana Vitrectomy. J Ophthalmic Vis Res 2012;7:118-24.  Back to cited text no. 5
  [Full text]  
Young AL, Leung GY, Cheng LL, Lam DS. A modified technique of scleral fixated intraocular lenses for aphakic correction. Eye (Lond) 2005;19:19-22.  Back to cited text no. 6
Madhivanan N, Sengupta S, Sindal M, Nivean PD, Kumar MA, Ariga M. Comparative analysis of retropupillary iris claw versus scleral-fixated intraocular lens in the management of post-cataract aphakia. Indian J Ophthalmol 2019;67:59-63.  Back to cited text no. 7
[PUBMED]  [Full text]  
Rashada DM, Omar MM, Gamal A.M., Khattabb HA. Retropupillary fi xation of iris-claw intraocular lens versus trans-scleral suturing fi xation for aphakic eyes without capsular support; Journal of Egyptian Ophthalmological Society 2015;108:157-66.  Back to cited text no. 8
Jain V, Waghmare L, Shrivastav T, Mahakalkar C. SNAPPS Facilitates Clinical Reasoning in Outpatient Settings. Education for Health: Change in Learning and Practice 2018;31:59-60. Available from: https://doi.org/10.4103/1357-6283.239052. [Last accessed on 2019 Oct 14].  Back to cited text no. 9
Jaiswal S, Banait S, Daigavane S. A Comparative Study on Peripapillary Retinal Nerve Fiber Layer Thickness in Patients with Iron-Deficiency Anemia to Normal Population. J Datta Meghe Inst Med Sci Univ 2018;13:9-11. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_82_17. [Last accessed on 2019 Oct 14].  Back to cited text no. 10
Khatib M, Sinha A, Gaidhane A, Simkhada P, Behere P, Saxena D, et al. A Systematic Review on Effect of Electronic Media among Children and Adolescents on Substance Abuse. Indian J Community Med 2018;43:S66-72. Available from: https://doi.org/10.4103/ijcm.IJCM_116_18. [Last accessed on 2019 Oct 14].  Back to cited text no. 11
Deolia S, Johny J, Patil MS, Lanje NR, Patil AV. Effectiveness of 'Audio-Tactile Performance Technique' to Improve the Oral Hygiene Status of Visually Impaired Schoolchildren. J Indian Soc Periodontol Prev Dent 2019;37:172-6. Available from: https://doi.org/10.4103/1319-2442.261344. [Last accessed on 2019 Oct 14].  Back to cited text no. 12
Taksande A, Meshram R, Lohakare A. A Rare Presentation of Isolated Oculomotor Nerve Palsy Due to Multiple Sclerosis in a Child. International Journal of Pediatrics 2017;5:5525-9. Available from: https://doi.org/10.22038/ijp.2017.24602.2075. [Last accessed on 2019 Oct 14].  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures

 Article Access Statistics
    PDF Downloaded64    
    Comments [Add]    

Recommend this journal