Occasionally, cataract surgeons run into intraoperative complications and decide that salvaging any vision is better than none. If the capsular bag is not suitable for insertion of the preselected IOL, the surgeon can place the lens in the sulcus, suture a posterior chamber lens to the iris, implant an anterior chamber IOL or simply leave the patient aphakic for the time being.

Suturing an IOL into the iris typically is done when there is a lack of structural capsular integrity or poor zonule support behind the iris. Among the numerous possible causes are chronic uveitis, retinitis pigmentosa, previous ocular surgery (e.g., glaucoma, retina), pseudoexfoliation and congenital syndromes (e.g., Marfan’s, homocystinuria). Ideally, the surgeon will be prepared for the likelihood of weak zonules or a loose lens, but this may not be discovered until the cataract surgery has begun.

The IOL haptics provide an adequate fixation point for securing the lens to the peripheral iris. Because specially made lenses for iris suturing do not fold, many retina surgeons prefer to use traditional three-piece IOLs that can be folded and inserted through a small scleral incision.

In the video posted online, the lens is positioned posterior to the iris using trocars and held in place while the lens is sutured with an anterior approach. With this method, the lens can be positioned and secured without large anterior chamber incisions. The natural lens was also removed by vitrectomy prior to IOL insertion.

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Click here to view a video of how this procedure is performed.

When comanaging these patients, understand that the visual outcome can be limited by preexisting disease, and that this technique of lens placement is far less accurate that traditional extracapsular cataract surgery. Patients may notice more visual distortion from the lens, but slight decentration of the lens typically does not cause a decrease in acuity; surgical repositioning rarely is warranted.

These cases are managed very similarly to a routine cataract surgery. There may be more inflammation within the eye due to the extended surgical time, which can be managed with anti-inflammatories appropriately. The comanaging optometrist will want to ensure that the lens remains fixated to the iris and there is not an excessive amount of poster- ior chamber inflammation.

Visual acuity is relatively stable immediately after surgery and may only be limited by ocular inflammation. Near correction can be beneficial immediately after surgery. Corrective lenses for distance can be prescribed at approximately one week. These patients typically are safe to dilate within days of surgery if necessary, but close communication with the surgeon is required to navigate any concerns with these abnormal cases.

Suturing IOLs to the iris is rarely the preferred technique for surgeons, but it does represent amazing ingenuity and allows the surgeon to get the best vision out of what is available. What’s truly remarkable about these cases is how well some patients can end up seeing.