TECHNIQUE

Iris fixation of unstable anterior chamber

intraocular lenses
Julio Narvaez, MD, Enoch Nam, MD

Cataract surgeons are sometimes challenged with a patient who has an unstable anterior chamber
intraocular lens (AC IOL). Over time, an unstable AC IOL can lead to significant complications. This
problem is most often addressed with an IOL exchange using an appropriately sized AC IOL or a
posterior chamber IOL with iris or scleral fixation. We present a technique of 2-point iris fixation of
unstable AC IOLs as a simpler and less traumatic alternative.
Financial Disclosure: Neither author has a financial or proprietary interest in any material or
method mentioned.
J Cataract Refract Surg 2016; 42:961964 Q 2016 ASCRS and ESCRS
Online Video

Complications associated with anterior chamber intra-
ocular lenses (AC IOLs) have significantly decreased
since the advent of flexible open-loop AC IOLs.1 In
the past, the flawed design of the closed-loop AC
IOL led to a high incidence of corneal decompensation,
chronic intraocular inflammation, cystoid macular
edema (CME), and glaucoma.2 The modern open-
loop AC IOLs are designed to have minimal vault
and some haptic flexibility, thus minimizing damage
to the corneal endothelium and angle structures. As
a result, numerous studies35 are finding open-loop
AC IOLs to be a safe and comparable alternative to
sutured posterior chamber IOLs (PC IOLs).
Despite advances in AC IOL design, improper sizing
of the IOL can lead to the same complications of closed-
loop IOLs. In general, these patients have IOL exchange
Submitted: February 15, 2016.
Final revision submitted: June 7, 2016.
Accepted: June 7, 2016.
From the Department of Ophthalmology (Narvaez, Nam), Loma Lin-
da University, Loma Linda, and the Delta Eye Medical Group
(Narvaez), Stockton, California, USA.
Presented in part as videos at the XXX Congress of the European
Society of Cataract and Refractive Surgery, Milan, Italy, September
2012, and at the ASCRS Symposium on Cataract, IOL and Refrac-
tive Surgery, Chicago, Illinois, USA, April 2012.
Corresponding author: Julio Narvaez, MD, 1617 Saint Marks
Plaza, Suite D, Stockton, California 95207, USA. E-mail:
narvaezjd@gmail.com.
with a proper-sized AC IOL or a PC IOL fixated to the
iris or sclera to prevent further complications. Explant-
ing these rigid AC IOLs requires large incisions, and
these exchange procedures carry the risks for surgically
induced astigmatism, suprachoroidal hemorrhage,
retinal detachment, and endophthalmitis.6
We report a simpler 2-point fixation technique of iris
fixation of the unstable AC IOL using a modified
Siepser knot as described by Osher et al.7 This is a valu-
able option to both patient and surgeon to resolve the
clinical problem while avoiding the risks of more com-
plex and traumatic surgeries.
SURGICAL TECHNIQUE
After a local block is placed, the eye is prepared and
draped in the usual sterile fashion for ophthalmic sur-
gery. A paracentesis is placed superiorly, inferonasally,
and inferotemporally. An intraocular miotic is used to
constrict the iris, and the anterior segment is filled
with an ophthalmic viscosurgical device (OVD). The
unstable AC IOL is then rotated to a horizontal posi-
tion, if the iris anatomy will allow, to evenly distribute
the weight of the AC IOL on the iris. A 10-0 polypro-
pylene suture on a long needle is entered through the
superior paracentesis to perforate the iris anteriorly
with the needle directed around the nasal optichaptic
junction. Subsequently, the iris is perforated again pos-
teriorly before exiting out to the limbus inferonasally. A
spatula is used to support the iris while the needle is
passed to facilitate penetration. A modified locking
Siepser knot is used to secure the haptic to the iris.

Q 2016 ASCRS and ESCRS http://dx.doi.org/10.1016/j.jcrs.2016.06.023 961

Published by Elsevier Inc. 0886-3350
962 TECHNIQUE: IRIS FIXATION OF UNSTABLE AC IOL
Figure 1. Iris-fixation of an unstable flexible open-loop AC IOL.
The sutures are cut using intraocular scissors. The tem-
poral optichaptic junction is sutured in the same
manner with the exception of using the inferotemporal
paracentesis sites. The anterior chamber OVD is finally
thoroughly irrigated out of the anterior chamber with a
balanced salt solution (Figures 1 and 2).
RESULTS
We have used this technique in 2 eyes of 2 patients, suc-
cessfully resolving AC IOL rotation and pseudophaco-
donesis. We encountered no complications during
follow-up, as has been the case with a previous larger
series of AC IOLs fixated to the iris.8 Video 1 (available
at http://jcrsjournal.org) shows the surgical technique.
DISCUSSION
The modern flexible open-loop AC IOL and advances
in surgical technique have reduced the incidence of
complications requiring IOL repositioning, exchange,
or removal.9 A comprehensive review of the literature
by Wagoner et al.3 showed that open-loop AC IOLs
are not susceptible to the high rates of corneal endothe-
lial decompensation, secondary glaucoma, and CME
associated with the older generation of closed-loop
AC IOLs. In addition, they found insufficient evidence
of the superiority of 1 IOL type or fixation site when
comparing open-loop AC IOLs with scleral or iris-
sutured PC IOLs for the correction of aphakia in eyes
without adequate capsule support.
The advantages of AC IOLs are that implantation is
less complex than scleral-wall fixation. The disadvan-
tages are that they are not recommended if the corneal
endothelium or angle structures are compromised. In
addition, inaccurate sizing of the AC IOL can lead to
complications. An oversized AC IOL can cause exces-
sive pressure on the iris root and angle recess, leading
to pupil ovalization, iris atrophy, hemorrhage, and
iritis.9 An undersized AC IOL might become mobile
J CATARACT REFRACT SURG - VOL 42, JULY 2016
Figure 2. Iris-fixation of an unstable flexible open-loop AC IOL.
and cause endothelial damage, iritis, peripheral ante-
rior synechiae, and glaucoma.9
The surgical management of an unstable AC IOL
typically involves exchange of the IOL. Recently, iris
fixation of unstable AC IOLs has been published.8
This method offers a less traumatic solution than an
IOL exchange using a 4-point fixation technique of
the AC IOL haptics to the iris. In 2009, one of the au-
thors (J.N.) independently conceptualized and imple-
mented a technique of AC IOL iris fixation that only
requires a 2-point fixation, securing the mobile IOL
by suturing the AC IOL at the optichaptic junctions.
This technique is more efficient than 4-point fixation
by reducing in half the number of intraocular knots
required for fixation. Although we have no experience
with 4-point fixation, our technique also appears
simpler to perform because first the suture is passed
more centrally in the cornea, where the anterior cham-
ber is deeper and there is more room to maneuver. Sec-
ond, the orientation during the needle pass (Figure 3,
broken vertical line) around the optichaptic junction
appears to be more ergonomic because it allows the
needle as it enters and exits the iris more space than
would be the case in 4-point fixation, where the exiting
needle must make a sharp upward turn to be able to
clear the peripheral haptic in an area with diminished
anterior chamber depth (Figure 3, broken horizontal
line).
Most IOL suture fixation techniques use 1 suture per
haptic. When properly performed, these 2-point fixa-
tion techniques have shown long-term effectiveness.
We have observed no tilting or pseudophacodonesis
in our patients who have had 2-point fixation and
anticipate this stability to continue.
After the suturing procedure, the anteriorly vaulted
AC IOL is pulled back toward the iris and each of the 2
haptics end up pressing evenly against the anterior
surface of the iris, effectively distributing pressure at
the entire area of irishaptic touch. This prevents
 TECHNIQUE: IRIS FIXATION OF UNSTABLE AC IOL
Figure 3. Diagram of suture passes with 2-point (left vertical hatched
line) and 4-point fixation (right horizontal hatched line).
tilting, rotation, and pseudophacodonesis. Moreover,
because the AC IOL in this situation is smaller than
usual, fixation to the iris effectively suspends the IOL
away from angle structures, further protecting the
endothelium and delicate angle structures.
Potential complications that might arise from iris fix-
ation of an AC IOL can be inferred from studies of iris-
fixated PC IOLs. Complications include iris chafing,
pigment dispersion, chronic inflammation and progres-
sive peripheral anterior synechiae formation, suture
breakage, untying of the knot, slippage of the haptic
from the suture, and degradation of the suture itself.10
Price et al.11 report 5 cases of late breakage of polypro-
pylene sutures used for iris fixation of poly(methyl
methacrylate) IOLs using the positioning hole of the op-
tic. Examination of all 5 sutures found that the suture
breakage occurred at the site where the suture came in
contact with the positioning hole. Parekh et al.12 used
a technique of suturing the PC IOL haptics to the iris
not using a positioning hole with no cases of subluxation
from suture breakage in more than 100 cases over
7 years. Anterior chamber IOL suture fixation to the iris
through the smooth, round optichaptic junction likely
offers some protection against late suture breakage.
In addition to suture location, the suturing technique
plays a role in long-term stability. Stutzman and Stark13
used McCannel sutures to fixate the PC IOL to the iris in
7 eyes, and 1 case of haptic dislocation occurred. Kaiura
et al.14 also used a simple McCannel suture for iris-
fixation of PC IOLs and reported 3 cases of postoperative
IOL slippage. More recently, Condon et al.15 and
Chang16 reported the incorporation of the Siepser sliding
knot with more favorable long-term results of secure
J CATARACT REFRACT SURG - VOL 42, JULY 2016
963
haptic to iris fixation. Condon et al.15 suggest that the
Siepser knot allows the suture ends to be pulled in oppo-
site directions, which allows more precise knot
tensioning and locking. In their study of 46 eyes with
iris fixation of the PC IOL using the Siepser knot, there
were no cases of haptic slippage. The modification of
the Siepser knot by Osher et al.7 results in a true locking
knot and might promote more secure long-term fixation.
In conclusion, 2-point iris fixation of the unstable
open-loop AC IOL using the modified Siepser knot ap-
pears to be an effective, simpler, and less traumatic
alternative to IOL exchange or 4-point iris fixation.
WHAT WAS KNOWN
 Patients with unstable AC IOLs can be treated with IOL ex-
change or 4-point iris fixation.
WHAT THIS PAPER ADDS
 Two-point iris fixation is a simpler and less traumatic
treatment option in patients with unstable AC IOLs.
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