Acta Ophthalmologica 2021

Review Article

Implantation of retropupillary iris-claw lenses: A

review on surgical management and outcomes
Liv Drolsum1,2 and Olav Kristianslund1,2
1
Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
2
Institute of Clinical Medicine, University of Oslo, Oslo, Norway

ABSTRACT. fixating an IOL to either the sclera or

Iris-claw lenses have gained increasing popularity over the last years and are by the iris. These options also apply to
many surgeons regarded as viable options in eyes with insufficient capsular or secondary IOL implantation or
zonular support. The iris-claw lens has two haptics with fine fissures for folding exchange surgery in eyes with insuffi-
(enclavating) the mid-peripheral part of the iris stroma and can either be placed cient capsular support.
in front of or posterior to the iris. In particular, the retropupillary implantation In choosing one approach over
has been increasingly chosen probably due to having an anatomical position another, the surgeon’s preference and
similar to that of the crystalline lens. The present review is based on a literature experience are major factors. Surgeons
review and also on the authors’ clinical experience with this lens, and it focuses have traditionally used angle-sup-
ported open-loop AC IOLs, not at
on surgical techniques and outcomes especially related to the characteristics of
least for their simplicity and relatively
this lens, having haptics with claws that fixate the lens to the posterior iris.
favourable outcomes (Drolsum 2003;
Implanting retropupillary iris-claw lenses has a relatively short learning curve, Wagoner et al. 2003; Chan et al. 2015).
and there are only few complications reported during surgery. Retropupillary Nevertheless, using those IOLs also
iris-claw lenses have demonstrated generally favourable efficiency and safety. risk compromising the corneal
However, the outcomes are probably more influenced by the reason for surgery endothelium and the AC angle, which
and eye comorbidity than the lens itself. Albeit seldom reported, the postoper- may eventually cause corneal decom-
ative complications have mostly been related to atrophy of the iris at the site of pensation and glaucoma in vulnerable
the haptics, or IOL decentration or disenclavation of one of the haptics. To date, eyes (Dick & Augustin 2001). Further-
however, there are few randomized clinical trials comparing this lens to other more, the AC IOLs are not foldable
lens alternatives in eyes exhibiting insufficient capsular or zonular support for and have the disadvantage of requiring
placing the lens in the ciliary sulcus. In the future, prospective studies with large an incision of approximately 6 mm.
samples should be performed to gain insights into the long-term safety of Considering those drawbacks, surgeons
retropupillary placed iris-claw lenses, and for comparisons with the various other often prefer to place IOLs in the PC,
techniques of lens fixation. with the IOL located away from the
AC angle and corneal endothelium, in
order to respect the eye’s anatomy.
Key words: artisan aphakia – iris fixated lens – iris-claw intraocular lens – iris claw intraocular
lens – retropupillary iris-claw intraocular lens – review – verisyse aphakia
However, scleral fixation, with or with-
out suturing, is often challenging and
time-consuming, and requires an expe-
Acta Ophthalmol. rienced surgeon (Kristianslund et al.
ª 2021 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica
Scandinavica Foundation. 2017c; Yamane & Ito 2021). Another
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs alternative is fixating the IOL to the
License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-
commercial and no modifications or adaptations are made.
iris. The haptics of the IOL can be
sutured from the posterior side of the
doi: 10.1111/aos.14824 iris (Wagoner et al. 2003; Condon et al.
in the capsular bag. However, if zonu- 2007; Dzhaber et al. 2020), or an IOL
Introduction lar support is compromised or capsular specially designed for sutureless iris
rupture complicates the surgery, then fixation, called an ‘iris-claw lens’, can
In uneventful cataract surgery, the
other options have to be considered. be applied.
standard procedure involves implant-
Viable alternatives include implanting Iris-claw IOLs have been in devel-
ing a foldable, one-piece posterior
an anterior chamber (AC) IOL or opment for nearly half a century,
chamber (PC) intraocular lens (IOL)

1
Acta Ophthalmologica 2021
beginning with Worst et al.’s (1972)
first iris-claw IOL in the early 1970s. In
the 1980’s, the first procedure for
implanting a retropupillary iris-claw
lens was described, followed by Rin-
jeveld et al.’s (1994) clinical results of
the anterior and posterior fixation of
iris-claw lenses. However, it was not
until the publication of Mohr et al.
(2002) that retropupillary iris-claw
lenses gained significant popularity for
treating aphakia. From this progressive
improvement in the design of iris-claw
IOLs, two identical models—the Ver-
isyse IOL for aphakia (VRSA54;
Abbott Laboratories, Inc., Abbott
Park, IL, USA) and the Artisan Apha-
kia IOL (Ophtec BV, Groningen, The
Netherlands)—have often been used.
Designed for aphakia, the Artisan/
Verisyse iris-claw lenses are rigid, one-
piece IOLs made of polymethyl
methacrylate (PMMA) with a 5.4-mm
optic and an 8.5-mm overall length
(Fig. 1). The haptics of this lens have
fine fissures to capture, by way of
enclavation, folds in the mid-peripheral
part of the iris stroma. For retropupil-
lary placement, the manufacturer-rec-
ommended A-constants using Sanders–
Retzlaff–Kraff (SRK) T formula are
116.9 (optical) and 116.8 (ultrasound).
For prepupillary placement, the rec-
ommended A-constants are 115.7 (op-
tical) and 115.0 (ultrasound).
In several eye clinics, the advantages
of using iris-claw lenses have recently
gained considerable attention, most
Fig. 1. Schematic of the iris-claw lens (Artisan Aphakia Model 205 lens, Ophthec BV, The
Netherlands)
2
likely because the implantation is sim-
pler and less time-consuming than the
different techniques of scleral fixations
as well as reports on similar efficiency
and safety compared to other options
(Jing et al. 2017; Kristianslund et al.
2017c; Dalby et al. 2019). In our
department, after iris-claw lenses were
introduced in 2006, implanting the
Verisyse/Artisan lenses has gradually
become our procedure of choice in eyes
with insufficient capsular support
(e.g.in secondary IOL implantation,
when IOL exchange is chosen due to
IOL dislocation and when cataract
surgery has involved complications).
Based on the literature and our
extensive experience with this lens, we
will in this review discuss the use of
retropupillary iris-claw lenses, particu-
larly regarding preparation for surgery,
techniques of implanting these lenses
and strategies for managing any com-
plications during or after surgery with
special focus on factors related to the
design of these lenses with claws fixated
to the posterior part of the iris. We also
discuss the postoperative outcomes,
especially in terms of efficiency and
safety.
Methods and Literature
Search
A search strategy was developed in
collaboration with the Medical Library
at Oslo University Hospital /
University of Oslo. The search was
restricted to English language with no
time restriction. It was finished in
December 2020 and was performed in
PubMed (Medline), Embase and
Cochrane Database of Systematic
Reviews. In PubMed (Medline), we
performed a search using the text
words ‘iris claw’ and ‘iris claws’, which
resulted in 282 publications. We also
performed a search using the addi-
tional keywords ‘Artisan aphakia’ or
‘Verisyse aphakia’, which yielded
another 24 publications, to a total of
306 articles that were initially viable for
our review. The searches in Embase
and Cochrane Database of Systematic
Reviews did not reveal any additional
possibly relevant articles.
The two authors independently
screened the abstracts of all 306 articles
for the ones possibly containing infor-
mation about implanting retropupil-
lary iris-claw IOLs. These articles were
reviewed in full-text versions and we
evaluated whether retropupillary Arti-
san or Verisyse iris-claw surgeries were
involved and, if so, the proportion of
patients.
After excluding studies on phakic
iris-claw IOLs and studies with fewer
than 20 eyes, follow-up times less than
the mean and median of 6 months,
paediatric cases and iris-claw lenses
other than Verisyse and Artisan, we
identified 17 studies either exclusively
or partly addressing the implantation
of retropupillary iris-claw lens
(Tables 1 and 2). Two of them were
randomized clinical trials (RCT)s, of
whom one had several publications
(Helvaci et al. 2016; Kristianslund
et al. 2017a, 2017b, 2017c; Dalby
et al. 2019; Dalby et al. 2020), whereas
one was a prospective case series
(Baykara et al. 2007). Of the 14 retro-
spective studies, seven were compara-
tive (Rufer et al. 2009; Hernandez
Martinez & Almeida Gonzalez 2018;
Mora et al. 2018; Tourino Peralba et al.
2018; Toro et al. 2019; Vounotrypidis
et al. 2019; Woo et al. 2020), whereas
the rest were case series. The compar-
ative studies (two prospective and
seven retrospective) focused on retrop-
upillary iris-claw lenses versus reposi-
tioning of the dislocated IOL–capsule
complex with sutures to the sclera
(Kristianslund et al. 2017c) or versus
prepupillary iris-claw lenses (Helvaci
et al. 2016; Hernandez Martinez &
Almeida Gonzalez 2018; Mora et al.
 Table 1. Studies of retropupillary iris-claw IOL implantations (Verisyse/Artisan) in terms of refractive and visual outcomes

Outcomes at last follow-up (mean  1SD or %)

Follow-up,
mean or Spherical
No of median A-constant BCVA BCVA equivalent Prediction Corneal cylinder
Study eyes1 Design (m2;y3) Incision /Formula (LogMAR) ≥ 20/40 (D) error (D) (D) SIA (D)

Baykara et al., 2007 32 Noncomparative, 9m Scleral tunnel 116.5/SRK-T nr 87.5 -0.70  0.47 -0.13  0.28/ Preop4: nr
interventional case absolute p.e.: 1.08  0.55D/
series 0.26  15 po5 --2.1  0.81
R€
ufer et al. 2009 22 Retrospective 17 m nr/open-sky nr 0.5/0.1 nr nr nr nr nr
comparative
Hsing et al. 2012 266 Retrospective >6 m Scleral or 117.0/nr nr 58 +0.23 nr nr nr
corneal
Sch€
opfer at al. 2012 51 Retrospective 2.4 y nr nr 0.25  0.2 nr -0.65  0.2 nr nr nr
(Snellen)
Gonnermann et al. 23 Retrospective 18 m Open-sky 117.0/nr 1.0  0.46 nr nr nr nr nr
2013
Schallenberg et al. 31 Retrospective 25 m Scleral tunnel 116.8/SRK-II 0.64  0.62 nr -0.43  1.93 nr nr nr
2014
Forlini et al. 2015 320 Retrospective 5.3 y Corneal 116.5/SRK-T 0.6/0.3/0.6 nr nr -1.42  1.22/ nr nr
1.5  1.15/
2.4  2.1
Choragiewicz et al. 47 Retrospective case 16 m Corneal or ACD-C:4.21, 0.46  0.27 44.7 nr -0.27  1.28 -1.82  1.07 -0.3  1.26
2016 series scleral A0-C:-0.25, (Snellen)
A1-C:0.4,
A2-C:0.1 /
Haigis
Helvaci et al. 2016 20 Prospective RCT 6m Corneal 117.0/nr 0.5  0.23 nr -0.25  1.75 nr nr nr
Faria et al. 2016 66 Retrospective case 23 m Corneal 116.5/SRK-T 0.35  0.40 nr nr 1.75  1.22 nr nr
series
Kristianslund et al. 50 Prospective RCT 6 m/2 y Scleral tunnel 116.9/SRK-T 0.22  0.30 76 (2 y) -0.06  1.21 +0.29  0.86 1.22  0.83 1.12  0.85 (6 m)
2017a;2017b;2017c; (2 y) (2 y) (6 m) (6 m)
Dalby et al. 2019,
2020
Hernandez Martinez 44 Retrospective 33 m Corneal or 116.8/nr 0.09  0.32 72.7 0.10  1.17 nr nr 2.49  1.36
et al. 2018 comparative scleral (corneal)
0.73  0.62
(scleral) 7
Tourino Peralba 38 Retrospective 12 m Corneal 116.8/nr 65 ETDRS nr nr nr Preop4: 1.3/ Po5: nr
et al. 2018 comparative (median) letters 1.8 (median)
(median)
Vounotrypidis et al. 40 Retrospective case 17 m Scleral nr/different 0.42  0.48 nr -0.32  1.32 0.11  1.06/ nr nr
2019 series formulas absolute p.e.:
+0.81  0.68
Mora et al. 2018 32 Retrospective 12 m Corneal 116.5/SRK-T 0.37  0.50 nr -1.02  1.51 nr 1.08  0.43 nr
comparative
Acta Ophthalmologica 2021

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Acta Ophthalmologica 2021

2018; Tourino Peralba et al. 2018; Toro

et al. 2019). Woo et al (2020) compared
different IOL types including retrop-

absolute p.e. = absolute prediction error, BCVA = best-corrected distance visual acuity, D = dioptres, nr = not reported, RCT = randomized clinical trial, SIA = surgically induced astigmatism.
SIA (D)
upillary iris-claw IOL in Descemet
stripping automated endothelial ker-

nr

nr
atoplasty. In the last two studies, this
Corneal cylinder
lens was implanted either with or
without penetrating keratoplasty or
compared with various other types of
IOL fixation (Rufer et al. 2009;
Vounotrypidis et al. 2019). Of the

Only reports with 20 patients or more are included, at least mean/median follow-up of 6 months, and in English language. Studies on paediatric patients are excluded.
(D)

nr

nr
reviewed studies, nine included only
the Artisan lens (Baykara et al. 2007;
Schallenberg et al. 2014; Forlini et al.
2015; Helvaci et al. 2016; Hernandez
Prediction
error (D)

Martinez & Almeida Gonzalez 2018;

Outcomes at last follow-up (mean  1SD or %)

Mora et al. 2018; Tourino Peralba et al.

nr

nr

2018; Toro et al. 2019), four included

only the Verisyse lens (Schopfer et al.
equivalent

2012; Faria et al. 2016; Kristianslund

Spherical

et al. 2017c; Vounotrypidis et al. 2019),

(D)

while four included both (Rufer et al.

nr

nr

2009; Hsing & Lee 2012; Gonnermann

(3 y, ≥0.6)

et al. 2013; Choragiewicz et al. 2016;

≥ 20/40

Woo et al. 2020).

BCVA

33.3
nr

Indications for Surgery

0.13  0.15
(LogMAR)

A retropupillary iris-claw IOL is suit-

BCVA

able when implanting an IOL in the

nr

ciliary sulcus is infeasible due to insuf-

ficient capsular and/or zonular sup-
116.5/SRK-T

116.9/SRK-T

port. Such cases often result from

A-constant
/Formula

severe complicated cataract surgery,

lens surgery in eyes with compromised
zonulae (i.e. ectopia lentis and
advanced pseudoexfoliation syn-
drome), IOL exchange surgery and
secondary IOL implantation. Even so,
Corneal
Incision

Scleral

the iris and the pupil place some

restrictions upon the procedure.
Follow-up,
mean or
median
(m2;y3)

Iris
Not distinguished between pre and retropupillary position.
3.9 y
5y

For an iris-claw lens to be implanted, the

iris needs sufficient support. Still, the
IOL can be implanted in case of minor
Number of eyes followed for at least 6 months.

iris defects and following iris recon-

Retrospective

Retrospective
comparative

comparative

struction, as described for both the

prepupillary position (Hu et al. 2016)
Design

and the retropupillary position (Forlini

Preop = preoperative measurement.
Po = Postoperative measurement.

et al. 2015). Although pronounced,

general atrophy of the iris frequently
Number of eyes at inclusion.
No of
eyes1

prohibits the use of iris-claw IOLs,

93

25

localized atrophy does not, provided

that such areas can be avoided. Beyond
Table 1 (Continued)

that, most surgeons resist performing

Toro et al. 2019

Woo et al. 2020

the procedure in eyes with profound

m = months.

iridodonesis due to the postoperative

y = years.

risk of trembling vision. Authors have

Study

reported excluding eyes with rubeosis

iridis as well (Forlini et al. 2015).
1
2
3
4
5
6
7

4
 Table 2. Studies of retropupillary iris-claw intraocular lens (IOL) implantations (Verisyse/Artisan) in terms of safety

IOL IOP Retinal

No of Follow-up Ovalisation Iris atrophy decentration Re-dislocation elevation ECL (%)/ detachment
Study eyes1 (m2y3) (%) (%) (%) (%) (%) Cells/mm2 CME (%) (%)

Baykara et al., 2007 32 9m 12.5 nr 0 0 19 nr nr 0

R€
ufer et al. 2009 22 17 m nr nr 4.5 9 4.5 nr nr 0
Hsing et al. 2012 266 >6 m 18 24 6 0 0 nr nr 0
Sch€
opfer at al. 2012 51 2.4 y nr nr nr nr nr nr 2 nr
Gonnermann et al. 2013 23 18 m 13 nr nr 13 0 Preop4 2325  240 /Po5 4.3 0.3
1319  211
Schallenberg et al. 2014 31 25 m 32 13 0 0 3 nr 0 3
Forlini et al. 2015 320 5.3 y 5 nr nr 1.3 2.2 Preop4: 2227  524 /Po5: 0.9 0.3
2170  432
Choragiewicz et al. 2016 47 16 m 17 6.4 2 nr 2 nr nr 2
Helvaci et al. 2016 20 6m 10 nr 0 0 25 nr 0 0
Faria et al. 2016 66 23 m 24 nr 0 1.5 18 Po5: 1768  741 4.5 1.5
Kristianslund et al. 2017a; 50 6 m/2 y nr nr 3 (2 y) 3 (2 y) 21 (6 m) 15.3 (2 y) 10 (6 m) 0 (2 y)
2017b; 2017c; Dalby et al.
2019, 2020
Hernandez Martinez et al. 2018 44 33 m nr nr nr nr Not specified7 4.4% (1 year) Not specified7 Not specified7
Tourino Peralba et al. 2018 38 12 m (median) 7.9 2.6 nr 2.6 Uncertain8 Reduction: 150  406 7.9 2.6
Vounotrypidis8 et al 2018 40 17 m nr nr nr nr nr nr nr nr
Mora et al. 2018 32 12 m nr nr 3 0 22 Preop4: 2047  489 25 3
Po5: 1395  380
Toro et al. 2019 93 5y 2.1 nr 0 2.1 22.5 Reduction: 176  9.5 2.1 1
Woo et al. 2020 25 3.9 y nr nr nr 12 28 19.3 1 0

Only reports with 20 patients or more are included, at least mean/median follow-up of 6 months, and in English language. Studies on paediatric patients are excluded. Study designs are reported in Table 1.
CME = cystoid macular oedema, ECL = endothelial cell loss, IOP = intraocular pressure, nr = not reported
1
Number of eyes at inclusion
2
m = months
3
y = years
4
Preoperative measurement (mean  SD)
5
Postoperative measurement (mean  1SD)
6
Number of eyes with at least 6 months follow-up
7
Only reported for both the pre and retropupillary iris-claw lens groups
8
Complications not distinguished between iris-claw lens and other IOL fixation types
Acta Ophthalmologica 2021

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Acta Ophthalmologica 2021
Pupil
To implant a retropupillary iris-claw
IOL, the pupil should ideally be of
normal size and shape. Although
using such lenses is possible with
dilated pupils—for instance, after
traumatic sphincter damage—widely
dilated pupils may cause patients to
experience optical disturbances from
the edges of the optic and the haptics,
and safely enclavating the haptics
may be technically demanding. Nev-
ertheless, combined pupilloplasty and
retropupillary iris-claw lens implanta-
tion in eyes with traumatic mydriasis
has been reported (Mikropoulos et al.
2019). In cases of extreme miosis,
IOLs should probably be placed ante-
rior to the iris in order to prevent
sphincter lesions during implantation.
Uveitis
Despite the lack of clear recommenda-
tions for using iris-claw IOLs in eyes
with uveitis, one may speculate that
fixating the haptics to the iris can con-
tribute to a prolonged inflammatory
response in such eyes, and in most
studies, eyes with active uveitis have
been excluded (Baykara et al. 2007;
Helvaci et al. 2016; Kristianslund et al.
2017c). However, in one report includ-
ing a case series of 11 patients with a
history of uveitis, it was concluded that
it was safe to use a prepupillary iris-claw
lens (Negretti et al. 2019). Although our
search did not return any literature
specifically focused on the retropupil-
lary placement of iris-claw lenses in eyes
with uveitis, the location—that is, ante-
rior or posterior to the iris—is presum-
ably irrelevant in such cases.
Preparation for Surgery
Anticoagulants and antiplatelet therapy
Our search did not return any literature
addressing whether anticoagulants
and/or antiplatelet therapy should be
temporarily discontinued prior to
implanting an iris-claw IOL. Regarding
cataract surgery, authors have gener-
ally agreed that such treatments can be
continued when topical anaesthesia,
corneal incision and phacoemulsifica-
tion are planned and when no compli-
cations from surgery are expected
(Bonhomme et al. 2013; Kiire et al.
2014; Grzybowski et al. 2015). At the
6
same time, surgeons have often
reported using peribulbar or retrobul-
bar anaesthesia and scleral pocket
incision while implanting iris-claw
IOLs (Baykara et al. 2007; Faria et al.
2016; Kristianslund et al. 2017c; Toro
et al. 2019) and would presumably opt
to discontinue anticoagulants and/or
antiplatelet therapy when such anaes-
thesia is needed. Against that expecta-
tion, however, a comparative study
with 750 patients in each group using
oral anticoagulants showed that no
severe haemorrhaging occurred after
peribulbar blocks (Calenda et al. 2014).
Although enclavation may also risk
haemorrhaging, the literature shows no
evidence of serious bleeding from this
manoeuvre. All risks considered, tem-
porarily discontinuing those treat-
ments, if possible, prior to implanting
iris-claw IOLs seems reasonable. Even
so, following the advice of the patient’s
internist or cardiologist, we have per-
formed the procedure without discon-
tinuing those treatments, because
risking minor haemorrhaging was
preferable to risking the patient’s car-
diovascular condition.
Anaesthesia
Unlike in ordinary cataract surgery, we
do not recommend topical anaesthesia
while implanting iris-claw IOLs, as
enclavation may induce pain. Accord-
ing to the literature, most surgeons
seem to prefer peribulbar, subtenon or
retrobulbar anaesthesia (Mohr et al.
2002; Baykara et al. 2007; Forlini et al.
2015; Faria et al. 2016; Fouda et al.
2016; Helvaci et al. 2016; Kristianslund
et al. 2017c; Mora et al. 2018; Toro
et al. 2019). By contrast, Tourino
Peralba et al. (2018) reported using
either peribulbar or topical anaesthesia
depending on the surgeon’s preference.
We have not identified any reports
using solely topical anaesthesia or that
have compared types of anaesthesia
while implanting iris-claw IOLs.
Pupil
We recommend neither pupil dilation
nor constriction as part of the preoper-
ative preparation of eyes scheduled for
secondary implantation of retropupil-
lary iris-claw IOLs. Otherwise, in cases
of IOL exchange or cataract surgery,
both of which require pupil dilation,
injecting a constrictive medicament (e.g.
acetylcholine, carbachol or pilocarpine)
often precedes the iris-claw enclavations
(Baykara et al. 2007; Schallenberg et al.
2014; Forlini et al. 2015; Faria et al.
2016; Fouda et al. 2016; Helvaci et al.
2016; Toro et al. 2019). However,
because a miotic pupil can be trauma-
tized when the two haptics are placed
behind the iris, the pupil size should be
evaluated before the constricting drug is
injected, which should proceed slowly in
order to control the pupil’s size. We
prefer a pupil size of 4 to 5 mm, as also
suggested by Mohr et al. (2002).
Surgical Technique
Paracentesis
Most surgeons prefer to make stab
incisions (one or two) before the main
incision—that is, when the eye remains
normotensive (Baykara et al. 2007;
Forlini et al. 2015; Faria et al. 2016).
For the one stab incision technique, we
prefer to have the side-port in the
temporal position in order to avoid
interference from the nose. However,
others have reported preferring the sur-
geon’s nondominant side at the 3 or 9
o’clock position in the left and right
eyes, respectively (Forlini et al. 2015).
Two incisions, placed nasally and tem-
porally, represent another option (Faria
et al. 2016).
Incision
A disadvantage of iris-claw lenses is the
rigid PMMA material that requires an
incision of 5.4 mm. Although authors
have reported using a corneal or limbal
incision (Table 1), a scleral pocket
incision at the 12 o’clock position
reduces the possibility of surgically
induced astigmatism (SIA), is less vul-
nerable to wound leakage (McDonnell
et al. 2003) and could be associated
with a lower risk of endophthalmitis
(Tab an et al. 2005). Making a scleral
incision with a long tunnel into the
cornea before entering the AC requires
some surgical experience, however.
Possible complications include prema-
ture perforation, which can cause the
uveal tissue to prolapse in the incision
and increased risk of bleeding into the
AC (John et al. 1992). Thin scleral
flaps, on the other hand, can cause
superficial lesions. However, we prefer
to make a limbal corneal incision in
cases of thin, brittle conjunctiva or

pronounced adherence between the
conjunctiva and episclera or sclera.
Such incisions may also be used in
previous filtering surgery in order to
prevent interference from the filtration
bleb (Kristianslund et al. 2017c). In
those cases, it is possible to make the
scleral pocket incision away from the
trabecular area. Even so, it may be
wiser to reserve that area for additional
filtering procedures that may become
necessary in the future.
Implantation of the lens
Any capsular remnants should be
removed before IOL implantation due
to the risk of IOL instability from
postoperative capsule fibrosis (Forlini
et al. 2015; Choragiewicz et al. 2016;
Faria et al. 2016), and depending on the
reason for surgery, anterior or posterior
vitrectomy should be performed, if nec-
essary. After viscoelastics are injected,
the IOL, while upside–down (i.e. con-
cavity anteriorly oriented), is inserted
into the AC by forceps, turned to the
horizontal position and centred on the
pupil. Many surgeons prefer special
forceps for fixating the IOL in the AC.
By fixating the middle of the optic, one
of the haptics can be slipped behind the
pupil with the IOL maintained in a
horizontal position. Prior to enclava-
tion, the correct position of the IOL,
with the optic centred in the pupil,
should be ensured while a special
enclavation spatula or a thin bent spat-
ula/a blunt needle is simultaneously
introduced via the stab incision. Next,
the IOL should be tilted against the iris
to visualize the claw configuration, after
which the enclavations can be made by
inserting the iris tissue into the claw.
Pressure should be minimized during the
procedure, or else the claw may extrude
in front of the iris. Further, the enclava-
tion of too much iris tissue risks pupil
ovalization. Last, the two dimples (i.e.
enclavations) in the iris should be iden-
tified in order to ensure the sufficient
fixation of the iris-claw lens (Fig. 2).
Peripheral iridectomy
When the iris-claw lens is placed on the
anterior surface of the iris, performing a
peripheral iridectomy has been recom-
mended (Mora et al. 2018; Toro et al.
2019). However, that procedure may be
unnecessary with the lens positioned
Fig. 2. A retropupillary iris-claw lens in position. The pupil is dilated and the lens is well centred.
The arrow to the left point at a clearly visible dimple corresponding to the enclavation in the iris.
The arrow to the right points to a small iris atrophy at the site of the enclavation
behind the iris. Indeed, in most studies
addressing retropupillary iris-claw
lenses, peripheral iridectomies have not
been performed (Baykara et al. 2007;
Forlini et al. 2015; Helvaci et al. 2016;
Kristianslund et al. 2017c; Toro et al.
2019).
Retropupillary iris-claw lens implantation
in IOL exchange surgery
In totally dislocated IOLs, that is grade
4 dislocation (Kristianslund et al.
2017c), implanting a retropupillary
iris-claw lens begins with pars plana
vitrectomy (PPV), after which the vit-
reoretinal surgeon can raise the IOL or
IOL–capsule complex with microfor-
ceps. Prior to that procedure, we prefer
to perform scleral pocket incision at
the 12 o’clock position. Next, the
second surgeon can grip the IOL once
it appears in the pupillary area, and
while the vitreoretinal surgeon releases
the haptic from the microforceps, the
second surgeon can extrude the IOL
and, if present, the lens capsule via the
incision without folding or cutting the
optic inside the AC.
Some surgeons also prefer to per-
form PPV while the IOL remains visible
in the pupillary area, that is grade 1–3
(Faria et al. 2016). Others apply an
anterior approach by fixating the IOL
and, if present, the capsule by using
forceps and carefully rotating the lens
into the AC prior to explantation. Prior
to this manoeuvre, injecting viscoelas-
tics both anterior and posterior to the
IOL can protect the corneal endothe-
lium and push the vitreous posteriorly,
respectively. Once the IOL is explanted,
Acta Ophthalmologica 2021
the implantation of the iris-claw lens
can proceed as described above.
Retropupillary iris-claw lens implantation
in cataract surgery
In cataract surgery complicated by
zonular dialysis or capsular rupture
such that capsular support is insufficient
for placing the IOL in the ciliary sulcus,
one of the alternative options is implant-
ing a retropupillary iris-claw lens. Such
IOLs are also suitable alternatives in
eyes with severe pre-existing zonular
defects, as in cases of advanced pseu-
doexfoliation syndrome, ectopia lentis
(i.e. Marfan syndrome) and lens dislo-
cation due to trauma. Depending upon
the degree of complication and the
surgeon’s preference, the IOL can be
implanted during the primary surgery or
else postponed. Postponing might some-
times be a reasonable decision in chil-
dren, that is Marfan syndrome or
congenital cataract, considering growth
of the globe and correct IOL power. If in
primary surgery, a clear corneal tempo-
ral incision is often preferred, one that
can be widened once the lens has been
removed in order to fit the size of the iris-
claw lens (Choragiewicz et al. 2016). We
rather prefer to use this temporal inci-
sion as a side-port and instead, a scleral
pocket incision at the 12 o’clock posi-
tion can be made, after which the iris-
claw lens may be implanted as described
above. If iris-claw lens implantation is
planned from the outset of cataract
surgery, then the main incision can be
performed at the 12 o’clock position and
widened before implanting the IOL
(Gonnermann et al. 2014).
7
Acta Ophthalmologica 2021
Complications during surgery
Although several studies have not
reported any complications during
surgery (Baykara et al. 2007; Helvaci
et al. 2016; Toro et al. 2019), a
few particular complications are not
uncommon. For one, enclavation may
cause lesions in the iris (Kristianslund
et al. 2017c), thereby requiring the
surgeon to consider a novel area for
the procedure. For another, if the
pupil is miotic (e.g. in pseudoexfolia-
tion syndrome), sphincter ruptures
may occur when the haptics are tilted
underneath the iris. In 50 retropupil-
lary iris-claw implantations, 18%
involved minor sphincter ruptures or
small lesions in the iris. However, the
sphincter lesions occurred most often
during the explantation of the dislo-
cated IOL–capsule complex, not dur-
ing the retropupillary placement of the
iris-claw lens (Kristianslund et al.
2017c).
Postoperative Results
Visual outcome
In otherwise healthy eyes, the visual
outcomes following retropupillary
implantation of iris-claw IOLs have
largely been satisfactory (Table 1). Of
course, the reason for surgery, a variety
of which have been reported in the
studies listed in Table 1, will pro-
foundly impact the outcome. In a
retrospective study of 320 eyes, the
postoperative mean LogMAR was 0.6
in retropupillary iris-claw lens implan-
tation in combination with a dislocated
crystalline lens; 0.3 in secondary iris-
claw IOL implantation in aphakia or
combined with the removal of a dislo-
cated IOL; and 0.6 in combination with
keratoplasty and vitrectomy (Forlini
et al. 2015). In another retrospective
study, the prepupillary (n = 87) and
retropupillary (n = 93) iris-claw lens
locations were compared after an aver-
age of 5 years with no significant dif-
ferences in visual outcomes (Toro et al.
2019). In an RCT comparing retrop-
upillary iris-claw lens implantation
with suturing the existing IOL to the
sclera in late in-the-bag IOL disloca-
tion, Dalby et al. (2019) found no
difference in corrected distance visual
acuity 2 years after surgery, 0.20 and
0.22 LogMAR, in the suturing and
exchange groups, respectively.
8
Surgically induced astigmatism (SIA)
The surgically induced astigmatism
(SIA) relates mostly to the size of the
incision. Because the lens material is
rigid, an incision of at least 5.4 mm is
necessary. A scleral pocket incision will
induce less astigmatism than a corneal
incision and is therefore preferred
(Hayashi et al. 2010; Kristianslund
et al. 2017a; Hernandez Martinez &
Almeida Gonzalez 2018). As shown in
Table 1, only three studies have
reported SIA, whereas two others have
reported both preoperative and postop-
erative corneal cylinders. One study
(Hernandez Martinez & Almeida Gon-
zalez 2018) reported SIA of 0.73  0.62
dioptres (D) with a scleral tunnel versus
2.49  1.36 D with a corneal incision
but did not distinguish the prepupillary
from the retropupillary iris-claw lens
positions during analysis. In another
study involving scleral pocket incision,
SIA was determined with vector analysis
by converting corneal cylinders to
Cartesian coordinates and found to be
0.65 D @ 171° after 6 months (Kris-
tianslund et al. 2017a).
Prediction error
For retropupillary placement, the man-
ufacturers of Verisyse/Artisan IOLs rec-
ommend an A-constant for the SRK-T
formula of 116.9 (optical) or 116.8
(ultrasound). Because many such surg-
eries involve aphakic eyes or eyes with
dislocated IOLs, newer IOL formulas
are infeasible, and in most studies, the
SRK-T formula has therefore been
used. In an overview of studies address-
ing IOL calculation in iris-claw implan-
tation, Huerva et al. (2017) reported that
in approximately 80% of the studies
involving retropupillary iris-claw lens,
the SRK-T formula had been used, of
which 60% had achieved a spherical
equivalent (SE) within  1.0 D using
different A-constants (i.e. 116.7–117.5).
However, other reports on refractive
outcomes have not mentioned the for-
mula or A-constants used, or whether
optical or ultrasound measurements
were performed, and from Table 1 it
can also be seen that the A-constant used
differs in the various studies. Six of the
reviewed reports describe analysing the
prediction error; four using the SRK-T
formula with A-constants varying from
116.5 to 116.9, whereas one report using
Haigis formula (Choragiewicz et al.
2016) and in one study different formu-
las seem to have been used (Vounotry-
pidis et al. 2019). In those six studies, the
mean prediction error varied from 2.4
to + 0.29 D. The high variation is likely
due to their analysing SE according to
either residual error or absolute error.
Further, refractive outcomes may also
depend upon the reason for surgery,
especially when combined with kerato-
plasty (Forlini et al. 2015). When per-
forming calculations based on refractive
outcomes after retropupillary iris-claw
IOL implantation in late in-the-bag IOL
dislocation, an optimized optical A-
constant of 117.3 has been suggested
(Kristianslund et al. 2017a). However,
given the dearth of reports with refrac-
tive outcomes and their mixed results,
additional studies with large samples are
needed, particularly ones that record
detailed information about formulas
and A-constants used, as well as causes
for the surgery, in order to determine a
more exact A-constant for aphakic Arti-
san/Verisyse lenses used in the retrop-
upillary position.
Pupil ovalization
Although round pupils are desired at
the end of surgery, pupils sometimes
develop horizontal ovalization in the
early postoperative period, at a fre-
quency as high as 32% (Table 2). Such
pupil ovalization is sometimes due to
early postoperative hypotony, and most
authors have reported that the phe-
nomenon is temporary and often does
not affect the diagnostic pupil dilation
(Baykara et al. 2007; Schallenberg et al.
2014; Faria et al. 2016). However,
enclavations not placed in the mid-
peripheral area but nearer the pupil
margin risk permanent ovalization.
Trembling vision and dull pain
Pronounced iridodonesis can cause
annoying pseudophacodonesis and
trembling vision. Forlini et al. (2015)
reported severe iridodonesis in five of
320 patients. Three cases complained of
blurred vision when leaning forwards,
and eight cases complained of chronic
dull eye pain. In view of those outcomes,
the authors proposed that the symptoms
could relate to the weight of the lens,
which may have pushed the iris towards
the cornea. Beyond that, however, liter-
ature reporting symptoms following
iris-claw lens implantation is scarce

and more studies focusing on those
postoperative aspects are needed.
Intraocular pressure (IOP)
No evidence suggests that iris-claw IOLs
induce permanent changes in intraocu-
lar pressure (IOP) or exacerbate glau-
coma. In fact, most studies have shown
only a modest rise in IOP, which
responds well to topical therapy and is
most often temporary (Baykara et al.
2007; Helvaci et al. 2016; Toro et al.
2019). One RCT revealed no clinically
significant differences in the frequency
of glaucoma or IOP in patients who
underwent IOL exchange for retrop-
upillary iris-claw lenses compared with
having the IOL repositioned in late in-
the-bag IOL dislocation (Kristianslund
et al. 2017b; Dalby et al. 2019).
Corneal endothelial cell loss (ECL)
When the iris-claw lens is fixated poste-
rior to the iris, the IOL is in a similar
position as the crystalline lens away
from the corneal endothelium—and the
risk of corneal endothelial cell loss
(ECL) is lower than with AC IOLs, at
least in theory. For the same reason,
ECL will likely occur during surgery,
with minimal loss in the postoperative
period. Obviously, cataract surgery
complicated by loose zonula, extremely
hard nucleus and vitreous loss may
induce a much higher ECL than the
simple implantation of a retropupillary
iris-claw lens in aphakia. Thus, the high
variation in ECL in different studies
(Table 2) probably mostly reflects dif-
ferent causes of surgery. In an RCT
addressing surgery for late in-the-bag
IOL dislocation, the 2-year postopera-
tive ECLs following IOL exchange with
a retropupillary iris-claw lens (15%)
versus repositioning the dislocated
IOL–capsule complex with scleral sutur-
ing (18%) did not significantly differ
(Dalby et al. 2020). Another retrospec-
tive study (Forlini et al. 2015) found no
significant difference between preopera-
tive and postoperative mean endothelial
cell density (n = 320) after 5 years on
average. A few other studies have com-
pared the position of the iris-claw lens
anterior versus posterior to the iris in
terms of postoperative ECL. Although
none of them revealed any significant
difference between the groups, all of
them suffered from small samples of eyes
(Hernandez Martinez & Almeida
Acta Ophthalmologica 2021
Gonzalez 2018; Mora et al. 2018; Tour- Disenclavation of the lens and iris atrophy
ino Peralba et al. 2018; Toro et al. 2019).
In the two retrospective studies with the
longest follow-up periods—5 years on
Cystoid macular oedema (CME) average in both—the disenclavation of
the haptics occurred at a rate of 1.3%
Cystoid macular oedema (CME) is a
and 2.0% (Fig. 3) (Forlini et al. 2015;
vision-threatening complication during
Toro et al. 2019). Disenclavation can
various intraocular surgeries, including
derive from insufficient primary
cataract surgery with vitreous loss
enclavation, which most often occurs
(Drolsum & Haaskjold 1995). The dif-
with inexperienced surgeons (Kim et al.
ferent reasons for combined surgery
2020), as well as from trauma (Kris-
with the implantation of a retropupil-
tianslund et al. 2017c). The atrophy of
lary iris-claw lens probably influence the
the iris at sites of enclavation, reported
frequency of CME. Mora et al. (2018)
in up to 24% of retropupillary iris-claw
reported a cumulative 12-month inci-
implantations (Table 2), can also cause
dence of 25% after surgeries of retrop-
disenclavation. Kim et al. (2020) identi-
upillary iris-claw implantation in either
fied 22 dislocations in 225 cases of
aphakia, dislocated IOL or subluxated
retropupillary iris-claw implantation
crystalline lenses. The results across
(9.8%) after an average of 90 days
studies may also vary according to time
postoperatively. They noted atrophy in
of follow-up, sample size and method of
59% of the cases involving dislocation
diagnosing CME. Only a few studies
and after face washing in 23%. They
involved performing macular optical
observed no cases of double disenclava-
coherence tomography in every case
tion. Due to the specific aim of their
and/or recording central macular thick-
study, this report is not part of the 17
ness (Table 2). In an RCT, we found no
studies included in the present review.
significant difference in the rate of CME
In disenclavation, the IOL can often
(10% vs. 7%) or change in central
be re-enclavated by an anterior
macular thickness (+11  70 µm vs.
approach, and for that purpose, we
+10  36 µm) at 6-month follow-up
prefer retrobulbar or peribulbar anaes-
comparing retropupillary iris-claw lens
thesia. In that approach, a small corneal
implantation to the scleral suturing of
incision is made superiorly and with one
the existing IOL in late in-the-bag IOL
side-port. Lens fixation forceps may be
dislocation (Kristianslund et al. 2017c).
used to hold and raise the lens (Kim et al.
Most authors have reported that
2020). However, due to the lack of
standard medication following the var-
counteraction, the lens is liable to move
ious surgeries involving iris-claw lens
away from the forceps when displaced in
implantation includes topical steroids
the vitreous. Therefore, it may be helpful
often combined with topical antibiotics
to place a cannula or blunt instrument
(Kristianslund et al. 2017c; Toro et al.
underneath the optic and raise the dislo-
2019). However, we have not found
cated side of the IOL to the AC. When
any studies reporting the impact of
the iris-claw lens is secured with the
prophylactic treatment with topical
forceps, it can be retropupillary encla-
nonsteroidal anti-inflammatory drugs
vated in the usual manner. Last, it is
on reducing the risk of CME.
Fig. 3. Disenclavation of one of the haptics of a retropupillary iris-claw lens. In the dilated pupil,
the optic is decentred, with the upper optic edge seen obliquely in the middle of the pupil area
9
Acta Ophthalmologica 2021
preferable to place the new enclavation in
fresh iris tissue away from the previous
site, which may have suffered lesions.
In cases when PPV has been per-
formed, it may be difficult to identify
the IOL in the vitreous through the
pupil in the supine position. In those
cases, a vitreoretinal approach should
be performed, with microforceps via the
pars plana, similar to what is described
above for totally dislocated IOLs.
Therefore, it is advisable to examine
patients in the supine position prior to
surgery in order to appropriately plan
their operations in these situations.
Decentration of the lens
Even if the two enclavations are intact
and the IOL is well-fixated to the iris, the
centration of the IOL depends upon
how well the IOL is centred during
surgery. Decentration has been reported
in up to 7.7% of cases (Table 2). How-
ever, it may not have clinical implica-
tions as long as the optic covers the
visual axis (Dalby et al. 2019).
Explantation of the lens
Although retropupillary iris-claw lenses
seldom need to be explanted, this may be
considered for refractive purposes, out of
decentration of clinical importance, or if
one of the haptics has been traumatized
and possibly altered (Brockmann et al.
2014). For explantation, we prefer to
dilate the pupil, make the scleral pocket
incision at the 12 o’clock position and
proceed with paracentesis at the tempo-
ral position, as described earlier. After
the optic has been fixated with the special
forceps, the enclavations can be released
with the thin spatula by applying gentle
pressure on the iris fold (Brockmann
et al. 2014). Going behind the iris to
release the iris from the haptic may also
be necessary. Such releasing manoeuvres
have to be extremely gentle due to the
risk of iris lesions.
Other complications
Because the iris-claw lens is fixated to the
iris, there is a possible risk of iritis during
the postoperative period. However, in
most studies, that complication has been
observed at low frequencies, reported as
0% (Forlini et al. 2015), 3% (Faria et al.
2016; Mora et al. 2018) and 6% (Dalby
et al. 2019). The reported rates of
retinal detachment after retropupillary
10
iris-claw implantation, clearly stemming
from the reason for surgery and the
comorbidity of the eye, have ranged
from 0% to 3% (Baykara et al. 2007;
Forlini et al. 2015; Helvaci et al. 2016;
Hsing & Lee 2012; Kristianslund et al.
2017c; Rufer et al. 2009; Schallenberg
et al. 2014; Toro et al. 2019; Tourino
Peralba et al. 2018; Woo et al. 2020). The
rate of endophthalmitis has also been
quite low; Gonnermann et al. (2012)
reported a frequency of 0.7% in a study
with 137 eyes and a mean follow-up
period of 5 months, whereas the com-
plication was not observed in any of the
included reviewed studies. Pigment dis-
persion has reportedly occurred at a
frequency of 0–3 % (Baykara et al. 2007;
Schallenberg et al. 2014; Forlini et al.
2015; Choragiewicz et al. 2016; Toro
et al. 2019).
Conclusion
An iris-claw lens placed retropupillary is
a suitable alternative in eyes with insuf-
ficient capsular or zonular support, such
as in cataract surgery with complica-
tions, conditions involving compro-
mised zonulae, secondary IOL
implantation and exchange surgery.
The anatomical localization behind the
iris, more biologically correct than the
original prepupillary position, leaves the
IOL away from the AC angle and
corneal endothelium. Compared with
other surgical options, retropupillary
iris-claw lens implantation is quite
quick, and complications during surgery
have been few. Due to the rigid design of
the lens, incisions may induce higher
astigmatism than foldable IOLs, and,
for that reason, scleral pocket incisions
are preferable. Iris-claw IOLs are suit-
able for most eyes, but should be avoided
in cases of profound general atrophy of
the iris, large iris defects or widely dilated
pupils, at least until iris or pupil recon-
struction has been performed. In terms
of visual outcomes, the procedure’s
results probably relate more to the
reason for surgery and eye comorbidity
than the lens itself. The postoperative
complications directly related to the lens
include pupil ovalization, iris atrophy at
the sites of enclavation and disenclava-
tion, although the rate of disenclavation
in the hands of experienced surgeons
is low. Uncertainty concerning the
A-constant remains and should be
investigated, as should postoperative
symptoms, such as trembling vision.
Randomized studies comparing iris-
claw lenses with other IOLs and surgical
options are also needed.
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Received on December 23rd, 2020.
Accepted on February 8th, 2021.
Correspondence
Olav Kristianslund, MD PhD
Department of Ophthalmology
Oslo University Hospital
Mailbox 4956 Nydalen
0424 Oslo
Norway
Tel: +47 22 11 85 45
Fax: +47 22 11 99 89
Email: olav.kristianslund@medisin.uio.no
The authors thank Hilde Flaatten at the Library of
medicine and science, University of Oslo, for
assistance with the literature search.
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