Pearls for Secondary Intraocular Lens Implantation

Pearls for Secondary Intraocular Lens Implantation

Secondary IOL implantation was traditionally performed for aphakia but is now most commonly done during IOL exchange surgery.

Preoperative Evaluation

Careful slit-lamp biomicroscopy with attention to:

  • Corneal endothelium
  • IOP
  • Presence of vitreous in anterior chamber
  • Angle and iris abnormalities
  • Presence and adequacy of capsular support, macula and peripheral retina, and optic nerve

IOL Selection

Posterior Chamber:

  • Capsular bag: best location for IOL if bag is intact with adequate support
  • Sulcus:
    • Adequate capsular support: Does not require suture; this is the next best location after capsular bag. Capture IOL optic through intact anterior capsulotomy if present.
    • Inadequate capsular support: Requires suture fixation to iris or sclera
      • Iris suture: Modified McCannel suture, tie with Siepser knot
      • Transscleral suture: Technically more difficult, longer procedure time, requires thorough anterior vitrectomy, risk of ciliary body hemorrhage and suture erosion.
  • Iris fixated: Iris-claw lens easiest surgical technique and fewer complications; requires peripheral iridectomy; also may be fixated to posterior iris surface.
  • Anterior chamber: Easier, faster and less traumatic than suture techniques; long-term results equivalent to sulcus with scleral suture fixation; requires peripheral iridectomy but may not require anterior vitrectomy; contraindicated if corneal endothelial damage, angle abnormalities, or glaucoma exists.

Surgical Technique

Posterior chamber:

  • Iris fixation: Capture IOL optic through pupil, place two McCannel-style sutures with 9-0 polypropylene on a long curved needle, retrieving needle can be facilitated by docking in cannula, Siepser knot minimizes traction on iris and haptics.
  • Scleral fixation: Numerous techniques with or without scleral flaps, secure with suture (9-0 polypropylene or 8-0 gortex on a long curved or straight needle) or glue. Safest techniques utilize 27-gauge hollow needle for precise positioning and docking/retrieving the suture needle. 

Iris-claw: Careful attention to centration during enclavation, must create peripheral iridectomy to prevent pupillary-block angle-closure glaucoma. Anterior chamber: constrict pupil, Sheet’s glide to facilitate insertion, push/pull-elevate-release haptic technique for proper footplate positioning in angle, must create peripheral iridectomy to prevent pupillary-block angle-closure glaucoma.


Friedman NJ, Khater TT, Kohnen T, Koch DD. "Secondary Intraocular Lens Implantation." In: Tasman W, Jaeger EA. (eds): Duane's Clinical Ophthalmology. Volume 6. Philadelphia. Lippincott, Williams, & Wilkins Publishers. 2011.

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