Clinical Insights into Iris-Claw IOLs in Aphakic Patients at a Tertiary Referral Centre

Clinical Insights into Iris-Claw IOLs in Aphakic Patients at a Tertiary Referral Centre | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Insights into Iris-Claw IOLs in Aphakic Patients at a Tertiary Referral Centre Robert Castledine, Luke O'Brien, Paul Connell This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7798031/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose : To examine the outcomes and complication rates of iris-claw intraocular lens (IOL) implantation in an aphakic cohort, with a comparison of anterior versus retropupillary enclavation, and an analysis of the biometric spread of implanted IOLs. Methods : In this single-centre retrospective case series, we analysed the medical records of 140 eyes from 134 patients who underwent iris-claw IOL implantation between April 2015 and July 2024. Analysis included patient demographics, surgical approach (anterior vs. retropupillary), lens strength, and both intraoperative and postoperative outcomes. Best-corrected visual acuity (BCVA) was evaluated preoperatively, at 3 months, and at 6–12 months postoperatively. Results : The mean preoperative BCVA was 1.13 logMAR, which improved to 0.47 logMAR at final follow-up (p < 0.001), with 94% of eyes achieving stable or improved vision. The difference in complication rates between anterior (27%) and posterior (18%) enclavation was not statistically significant (p = 0.59). Corneal decompensation only occurred in cases of anterior iris enclavation. Cystoid macular oedema (CMO) occurred in 22 eyes, with all uncomplicated cases resolving with steroid treatment. Late disenclavation of the IOL was a rare complication. Half of the patients achieved a final refraction within ±1D of target. The most commonly implanted lens strengths ranged between +17.0D and +20.0D. Conclusion : Iris-claw IOL implantation is a safe, effective option for aphakic patients lacking capsular support, even in a complex comorbid patient cohort. Our findings suggest that retropupillary placement may be a less traumatic alternative to anterior enclavation, though further evidence is needed. Iris-claw IOL Artisan aphakia retropupillary Figures Figure 1 Figure 2 What was known Iris-claw intraocular lenses (IOLs) represent a well-established option for aphakic patients without capsular support, with both anterior and retropupillary enclavation techniques in use. Prior studies have confirmed the general safety and efficacy of iris-claw IOLs, particularly in comparison to scleral-fixated and angle-supported lenses. Evidence comparing anterior versus retropupillary enclavation remains limited, especially regarding complication profiles and practical implications for surgical planning and lens stock management. What this paper adds This is the first study to report outcomes of Artisan iris-claw IOL implantation in an Irish cohort, offering real-world insights from a large population of complex patients referred to a tertiary-referral centre. Our findings reinforce growing evidence for the safety and efficacy of iris-claw IOL use in complex aphakic cases and suggest that retropupillary enclavation may offer a lower risk of endothelial complications, supporting their use in appropriate cases. The study also provides practical data on lens strength distribution, helping inform more efficient inventory strategies for centres establishing in-house lens banks. Introduction The preferred location for intraocular lens (IOL) insertion in aphakic patients is into the capsular bag with the IOL occupying a physiological position in the posterior chamber, replacing the crystalline lens and producing excellent optical and visual results in the majority of patients. In some patients, however, inadequate capsular support necessitates implantation of an IOL in another location. Approaches commonly used at present include angle-supported IOLs, scleral-fixated IOLs (including Yamane and Carlevale techniques), iris-sutured IOLs and iris-claw (Artisan) IOLs. There continues to be no consensus on the best and preferred method for IOL fixation in these patients, although all approaches have been shown to be safe and effective, despite potential associated complications across all techniques. An iris-claw approach has particularly gained favour in recent years. Artisan lenses with their updated intraocular design represent an excellent choice in suitable patients. A more recent development in iris-claw IOL implantation is the increasing use of a retropupillary approach, whereby the IOL is enclaved to the posterior surface of the iris, rather than enclaving anteriorly. This study presents the data from a sizeable cohort on outcomes and complication rates for aphakic Artisan implantation from a specialist eye unit. The primary aim of this study is to investigate the safety and efficacy of Artisan lens IOL insertion from a single centre. Secondary aims include investigating and commenting on the benefits or otherwise of anterior vs. posterior enclavation sites, as well as to review refractive outcomes. Furthermore, a comment on the biometric spread of implanted IOLs may assist other units in establishing modified lens banks for the management of their patients perioperatively. Methods This study was conducted as a single-centre retrospective case series on the basis of chart review. Theatre logs were used to identify all patients treated with Artisan IOLs at the Mater Misericordiae Hospital, Dublin, from April 2015 to July 2024. Data collection included: patient demographics; ocular comorbidities; indication for Artisan IOL; approach used (anterior vs. posterior iris enclavation); strength of IOL inserted; post-operative complications; post-operative intraocular pressure (IOP) at 1 month; visual outcomes; and final refractive outcomes. Visual outcomes were assessed on the basis of best corrected visual acuity (BCVA) on Snellen chart testing measured pre-operatively, BCVA at 3 months post-operatively, and final BCVA at 6–12 months. Patients followed up for less than 6 months were excluded from outcomes analysis. With regard to the surgical procedure, both anterior and posterior iris enclavation was employed. The exact surgical technique was adapted to suit each case in our varied patient cohort, including anterior approaches, pars plana vitrectomy (PPV), and Artisan insertion as part of a broader complex procedure. In brief, for anterior enclavation a 5.5–5.7 mm posterior 3-stepped limbal wound was created with two adjacent paracentesis. Following instillation of viscoelastic, the lens was inserted and dialled being careful to maintain the correct vault. 2 x 10-nylon sutures added stability to the anterior chamber and the needle enclavation was performed once the lens was well-centred. A peripheral iridotomy was created where not already present. The wound was closed with interrupted 10-nylon sutures. With respect to posterior enclavation, the lens was inserted with the opposite vault and fixed sequentially to the posterior iris when the impression of the haptic visualised in the correct position. The study was approved by the hospital’s Clinical Audit and Effectiveness Committee as a comparison of best practice. Statistical analysis Microsoft Excel (Version 16.88) was used for data collection, and analysis was performed using SPSS Statistics (Version 29.0.2.0). This included descriptive statistics and paired samples t-testing to compare BCVA LogMAR values across different timepoints. A significance threshold was set at a p-value of less than 0.05. VA was converted from Snellen to LogMAR using the formula provided by Tiew et al.[ 1 ] Snellen to LogMAR is converted as: counting fingers – 1.87 LogMAR; hand motions – 2.3 LogMAR; perception of light – 3 LogMAR; and no perception of light – 3.3 LogMAR. Results Artisan IOLs were implanted into 140 eyes (from 134 patients) between April 2015 and July 2024. The treatment group includes 82 male patients and 52 female patients, with an average age of 64.5 years (range: 19–101; SD: 17.7 years). The indications for Artisan IOL insertion are outlined in Table 1 , with the largest patient group being those left aphakic following complicated phacoemulsification (51 eyes; 37%) and patients with dislocated IOLs (39 eyes; 28%). Information on the specific indication could not be found for 3 eyes. The Artisan IOL was enclaved to the anterior iris in 123 eyes (88%) and posteriorly in 17 eyes (12%). Table 1 Indication for iris-claw IOL insertion Indication N (%) Complicated phacoemulsification 51 (37%) Aphakic following retinal surgery 1 (0.7%) Congenital cataracts 2 (1.4%) Dislocated crystalline lens 17 (12%) Dislocated IOL 39 (28%) IOL opacity 7 (5%) Trauma 20 (15%) Any pre-existing ocular comorbidities prior to Artisan IOL implantation were recorded for all patients and are listed in Table 2 . 67 eyes (48%) had one or more preexisting comorbidities; and 15 eyes (11%) had two or more. The most frequently occurring comorbidities recorded were retinal detachment (18 eyes; 22%), pseudoexfoliation syndrome (PXF) (8 eyes; 10%) and age-related macular degeneration (ARMD) (8 eyes; 10%). Table 2 Ocular comorbidities prior to iris-claw IOL insertion Comorbidity N % Retinal detachment 18 22% Pseudoexfoliation syndrome (PXF) 8 10% ARMD 8 10% Marfan's syndrome 6 7% Amblyopia 5 6% Homocystinuria 5 6% Diabetic retinopathy 5 6% Epiretinal membrane 4 5% Aphakia due to congenital cataracts 3 4% CMO 3 4% Vitreous haemorrhage 2 2% Corneal oedema 2 2% Glaucoma 2 2% Ocular hypertension 1 1% Diabetic macular oedema 1 1% Stickler's syndrome 1 1% BRVO 1 1% Retinitis pigmentosa 1 1% Gyrate atrophy 1 1% Bacterial keratitis 1 1% Macular hole 1 1% Pigment dispersion syndrome 1 1% Angle-closure glaucoma 1 1% Congenital glaucoma 1 1% LASIK 1 1% 114 eyes had at least 6 months follow-up and were included in analysis of BCVA outcomes (see Fig. 1): the mean pre-operative BCVA was 1.13 logMAR (SD: 0.68 logMAR); mean 3-month BCVA was 0.58 logMAR (SD: 0.61 logMAR); and mean final BCVA was 0.47 logMAR (SD: 0.57 logMAR). Paired samples t-testing revealed statistically significant improvement in mean BCVA from the pre-operative timepoint to 3-months post-operatively (p < 0.001), and further significant improvement in BCVA from 3-month to final follow-up (p < 0.001). Overall, BCVA remained stable or improved in 107 (94%) eyes, and 7 (6%) eyes showed a worsening of BCVA (see Table 3 ). Table 3 Patients with worsening of VA at final follow-up Patient VA pre-OP VA final Comment 1 0.48 0.60 Penetrating eye injury by nail 2 0.00 0.18 Penetrating eye injury with steel intraocular foreign body; lensectomy required 3 1.48 1.78 Stickler syndrome; corneal decompensation 4 1.00 3.30 Endophthalmitis 5 0.30 0.48 Trauma to eye; CMO 6 1.18 1.78 Preexisting amblyopia and retinal detachment 7 0.16 0.24 None A subgroup analysis of eyes treated with anterior vs. posterior iris enclavation showed a mean difference of 0.41 logMAR (95% CI: -0.15–0.84 logMAR; p = 0.029) favouring anterior enclavation. Further analysis for non-inferiority was not performed given the broad confidence interval, likely due to a limited number of cases included in the posterior enclavation group. Complications were recorded as intraoperative, early post-operative (up to 30 days) and late. All intraoperative complications were associated with complex trauma cases and eyes with significant comorbidities (e.g. RD, Stickler syndrome), whereby no intraoperative complications occurred associated with Artisan insertion alone. 5 eyes presented with early post-operative complications: 2 cases of increased IOP (both resolving within 1 month); 1 case of uveitis (in an eye with known PXF); and 2 cases of corneal oedema (in 2 complex trauma cases). There were 22 cases of late-onset CMO: all uncomplicated cases resolved following a course of topical or injected steroids (sub-tenons or intraocular). Final visual acuity at 12 months was reduced in only one eye affected by CMO, and this case involved significant eye trauma. Artisan disenclavation occurred as a late complication in 4 eyes: in 2 cases this was associated with trauma to the orbit, and in all cases a corrective follow-up procedure was successful. There was a single case of late-onset post-surgical endophthalmitis in a patient who had undergone multiple previous ocular procedures resulting in no perception of light and phthisis of the affected eye. Retinal detachments occurred during the follow-up period in 3 patients, including 1 patient with previous retinal detachment. No convincing association with Artisan implantation was identified in any case. No patients developed post-operative hypotony, and no new incidence of glaucoma was seen following surgery. Overall, 37 complications occurred with anterior iris enclavation (27% complication rate in this group), and 3 complications occurred following posterior enclavation (18% complication rate). Chi-squared comparison resulted in a value of 0.29 (p = 0.59). Refractive outcomes were available for a smaller subset of 48 eyes. The mean final refraction in dioptres was − 0.46 D (range: -5.5 to + 8.0 D; SD 1.97 D). 24 eyes (50%) achieved a final refraction within a range of -1 D to + 1 D. Information on the strength of Artisan lenses implanted (in dioptres) was available for 135 eyes. The mean lens strength was + 17.4 D (range: +6.0 D to + 27.0 D; SD: 4.2 D). Figure 1 shows the frequency of each strength of Artisan IOL inserted. Discussion For aphakic patients, Artisan IOL insertion has become increasingly popular over the past decade, and has been demonstrated to be safe and effective in multiple studies[ 2 – 4 ]. The procedure is relatively less invasive compared to a scleral fixation approach, which is associated with an increased risk of choroidal haemorrhage and retinal detachment[ 5 ]. Angle-supported IOLs may be considered as an alternative, but carry their own risks of both secondary glaucoma and endothelial decompensation, and must be carefully sized to ensure an exact fit[ 6 , 7 ]. Artisan lenses offer the advantage of more flexibility in sizing as they are fixed to the mid-periphery of the iris. Furthermore, iris movements are largely unimpeded, facilitating iris dilation for ophthalmological examination or further surgery[ 8 ]. Our data are derived from a large cohort of patients attending a quaternary referral centre in Dublin, Ireland, with many complex and chronic cases referred from other centres. We believe that this is the largest series currently in the literature examining this topic. This is reflected in the indications for Artisan insertion (Table 1 ), with 37% of patients being referred for Artisan implantation following complicated phacoemulsification. In the majority of these cases, patients were left aphakic following initial surgery to await a secondary Artisan procedure. Our data on preexisting ocular comorbidities also paint a picture of a complex and multimorbid group, with almost half of the eyes analysed being associated with at least one preexisting ocular condition. Despite this challenging cohort, we report positive BCVA outcomes in line with other studies involving complex patient groups[ 2 , 4 , 9 , 10 ]. Of the small group of 7 eyes with a BCVA which worsened from pre-treatment to final follow-up, 4 eyes represented complex ocular trauma cases. A further two cases had significant ocular comorbidities: Stickler syndrome; and a previous retinal detachment. The remaining patient had a history of multiple surgeries on the affected eye, including Artisan IOL implantation, resulting in post-operative endophthalmitis and secondary phthisis. It is interesting to note the modest, but significant, further improvements seen in BCVA from 3 months to 12 months post-operatively. It is at around 3 months that patients return for a follow-up appointment for removal of corneal sutures placed intraoperatively. The further improvements to BCVA beyond 3 months are likely therefore to be explained by resolution of astigmatism, as shown previously[ 11 ]. Beyond 6 months, BCVA tends to remain stable provided no complications occur, and this was reflected in our data. In recent years, Artisan lenses are more frequently being implanted in the retropupillary location – enclaved to the posterior iris – offering the optical advantages of an IOL positioned in the posterior chamber, combined with a relatively straightforward procedure which can be carried out via corneal incisions[ 12 ]. In our own anterior versus retropupillary comparison of BCVA outcomes were similar between groups. An advantage of posterior implantation is that IOLs implanted anterior to the iris are at greater risk of exposing the corneal endothelium to mechanical effects, leading to reduced endothelial cell counts and potential additional complications due to corneal decompensation[ 13 – 16 ]. In our analysis 5 cases of corneal decompensation were identified, all occurring with anterior iris enclavation and none in posterior placement. Whilst not significant, our work is supportive of the less traumatic nature of retropupillary placement. Analysis of refractive outcomes in a subgroup of patients provides some evidence of satisfactory refractive results, whereby half of eyes had a final refraction between + 1D and − 1D. Given that target final refraction is oriented on patient preference (i.e. target for reading, mid, or distance vision) some variation in final refraction is to be expected. Although it was not possible to collect data for refractive results for the majority of patients in our study, it was our experience that most patients were satisfied with the final refractive results. In our study, we were able to collect comprehensive information of the strength of Artisan IOLs implanted in every eye. This has allowed us to report on the most commonly used prescriptions to guide other centres in their ordering of lenses to be stocked in-house. The alternative – case-by-case lens ordering – is cumbersome, leading to treatment delays and often not allowing contemporaneous placement of this lens due to unavailability. Despite the clear advantages of an in-house lens bank, it can be difficult to target ordering to ensure the right stock levels. Our centre maintains a stock of lenses in the range of + 6.0D to + 27D, in 0.5D increments. Depending on case volumes at each centre, our data indicate that a sensible strategy could be to stock more than 1 unit within the range of + 14.0D to + 24.0D, and certainly to do so at the peak frequencies between + 17.0D and + 20.0D. The major limitations of this study are its retrospective design. Follow-up data for some patients was unavailable, often as they were followed up externally. A limited sample size of eyes in the posterior-iris enclavation group made meaningful comparison between anterior and posterior iris-enclavation approaches difficult, and a future study including a greater number of eyes with retropupillary Artisan IOLs would help clarify the efficacy of this emerging surgical approach. In conclusion, our study provides further evidence of the safety and efficacy of Artisan IOL implantation even in a complex comorbid cohort of aphakic patients with inadequate capsular support. Insights provided into lens strengths used in our large sample will be of great practical benefit to other centres establishing lens banks in order to optimise lens ordering. Further evidence is however required regarding the best option for iris enclavation. Declarations The study adhered to the Declaration of Helsinki and ethical standards for human research. Ethical approval was granted by the Clinical Audit and Effectiveness Committee of the Mater Misericordiae University Hospital. Informed consent was waived due to the retrospective, anonymised nature of the data. The authors declare that they have no conflict of interest. This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. No external sources of material or financial support were provided. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Robert Castledine and Luke O’Brien. The first draft of the manuscript was written by Robert Castledine and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Tiew S, Lim C, Sivagnanasithiyar T. Using an excel spreadsheet to convert Snellen visual acuity to LogMAR visual acuity. Eye (Lond). 2020;34(11):2148-9. Negretti GS, Chan WO, Muqit MMK. Artisan iris-claw intraocular lens implantation in vitrectomised eyes. Eye (Lond). 2021;35(5):1393-7. Chen Y, Liu Q, Xue C, Huang Z, Chen Y. Three-year follow-up of secondary anterior iris fixation of an aphakic intraocular lens to correct aphakia. J Cataract Refract Surg. 2012;38(9):1595-601. Güell JL, Verdaguer P, Elies D, Gris O, Manero F, Mateu-Figueras G, et al. Secondary iris-claw anterior chamber lens implantation in patients with aphakia without capsular support. Br J Ophthalmol. 2014;98(5):658-63. Bellucci R, Pucci V, Morselli S, Bonomi L. Secondary implantation of angle-supported anterior chamber and scleral-fixated posterior chamber intraocular lenses. Journal of Cataract & Refractive Surgery. 1996;22(2):247-52. Zeh WG, Price FW, Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 2000;26(7):1028-34. Hennig A, Johnson GJ, Evans JR, Lagnado R, Poulson A, Pradhan D, et al. Long term clinical outcome of a randomised controlled trial of anterior chamber lenses after high volume intracapsular cataract surgery. Br J Ophthalmol. 2001;85(1):11-7. Lett KS, Chaudhuri PR. Visual outcomes following Artisan aphakia iris claw lens implantation. Eye (Lond). 2011;25(1):73-6. Negretti GS, Chan WO, Pavesio C, Muqit MMK. Artisan-style iris-claw intraocular lens implantation in patients with uveitis. J Cataract Refract Surg. 2019;45(11):1645-9. Güell JL, Velasco F, Malecaze F, Vázquez M, Gris O, Manero F. Secondary Artisan-Verysise aphakic lens implantation. J Cataract Refract Surg. 2005;31(12):2266-71. Potamitis T, Fouladi M, Eperjese F, McDonnell PJ. Astigmatism decay immediately following suture removal. Eye (Lond). 1997;11 ( Pt 1):84-6. Drolsum L, Kristianslund O. Implantation of retropupillary iris-claw lenses: A review on surgical management and outcomes. Acta Ophthalmol. 2021;99(8):826-36. Kim M, Kim JK, Lee HK. Corneal endothelial decompensation after iris-claw phakic intraocular lens implantation. J Cataract Refract Surg. 2008;34(3):517-9. van Eijden R, de Vries NE, Cruysberg LP, Webers CA, Berenschot T, Nuijts RM. Case of late-onset corneal decompensation after iris-fixated phakic intraocular lens implantation. J Cataract Refract Surg. 2009;35(4):774-7. Schallenberg M, Dekowski D, Hahn A, Laube T, Steuhl KP, Meller D. Aphakia correction with retropupillary fixated iris-claw lens (Artisan) - long-term results. Clin Ophthalmol. 2014;8:137-41. Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmol. 2015;15:143. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":216269,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7798031/v1/0f793f7faf6de5e31144e0bb.png"},{"id":94623166,"identity":"68a81fc7-f56c-44a1-95a0-c6d09854ac9a","added_by":"auto","created_at":"2025-10-29 04:18:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":316574,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7798031/v1/35596023226efa90b4addac3.png"},{"id":98623681,"identity":"bc31b38a-ba29-4938-bc43-9c8a8de8db2b","added_by":"auto","created_at":"2025-12-19 17:07:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1002578,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7798031/v1/ac466f63-8b65-4572-83b4-4e0d4321c26d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Insights into Iris-Claw IOLs in Aphakic Patients at a Tertiary Referral Centre","fulltext":[{"header":"What was known","content":"\u003cul\u003e\n \u003cli\u003eIris-claw intraocular lenses (IOLs) represent a well-established option for aphakic patients without capsular support, with both anterior and retropupillary enclavation techniques in use.\u003c/li\u003e\n \u003cli\u003ePrior studies have confirmed the general safety and efficacy of iris-claw IOLs, particularly in comparison to scleral-fixated and angle-supported lenses.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Evidence comparing anterior versus retropupillary enclavation remains limited, especially regarding complication profiles and practical implications for surgical planning and lens stock management.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this paper adds\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThis is the first study to report outcomes of Artisan iris-claw IOL implantation in an Irish cohort, offering real-world insights from a large population of complex patients referred to a tertiary-referral centre.\u003c/li\u003e\n \u003cli\u003eOur findings reinforce growing evidence for the safety and efficacy of iris-claw IOL use in complex aphakic cases and suggest that retropupillary enclavation may offer a lower risk of endothelial complications, supporting their use in appropriate cases.\u003c/li\u003e\n \u003cli\u003eThe study also provides practical data on lens strength distribution, helping inform more efficient inventory strategies for centres establishing in-house lens banks.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe preferred location for intraocular lens (IOL) insertion in aphakic patients is into the capsular bag with the IOL occupying a physiological position in the posterior chamber, replacing the crystalline lens and producing excellent optical and visual results in the majority of patients. In some patients, however, inadequate capsular support necessitates implantation of an IOL in another location. Approaches commonly used at present include angle-supported IOLs, scleral-fixated IOLs (including Yamane and Carlevale techniques), iris-sutured IOLs and iris-claw (Artisan) IOLs. There continues to be no consensus on the best and preferred method for IOL fixation in these patients, although all approaches have been shown to be safe and effective, despite potential associated complications across all techniques.\u003c/p\u003e\u003cp\u003eAn iris-claw approach has particularly gained favour in recent years. Artisan lenses with their updated intraocular design represent an excellent choice in suitable patients. A more recent development in iris-claw IOL implantation is the increasing use of a retropupillary approach, whereby the IOL is enclaved to the posterior surface of the iris, rather than enclaving anteriorly.\u003c/p\u003e\u003cp\u003eThis study presents the data from a sizeable cohort on outcomes and complication rates for aphakic Artisan implantation from a specialist eye unit. The primary aim of this study is to investigate the safety and efficacy of Artisan lens IOL insertion from a single centre. Secondary aims include investigating and commenting on the benefits or otherwise of anterior vs. posterior enclavation sites, as well as to review refractive outcomes. Furthermore, a comment on the biometric spread of implanted IOLs may assist other units in establishing modified lens banks for the management of their patients perioperatively.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was conducted as a single-centre retrospective case series on the basis of chart review. Theatre logs were used to identify all patients treated with Artisan IOLs at the Mater Misericordiae Hospital, Dublin, from April 2015 to July 2024. Data collection included: patient demographics; ocular comorbidities; indication for Artisan IOL; approach used (anterior vs. posterior iris enclavation); strength of IOL inserted; post-operative complications; post-operative intraocular pressure (IOP) at 1 month; visual outcomes; and final refractive outcomes. Visual outcomes were assessed on the basis of best corrected visual acuity (BCVA) on Snellen chart testing measured pre-operatively, BCVA at 3 months post-operatively, and final BCVA at 6\u0026ndash;12 months. Patients followed up for less than 6 months were excluded from outcomes analysis.\u003c/p\u003e\u003cp\u003eWith regard to the surgical procedure, both anterior and posterior iris enclavation was employed. The exact surgical technique was adapted to suit each case in our varied patient cohort, including anterior approaches, pars plana vitrectomy (PPV), and Artisan insertion as part of a broader complex procedure. In brief, for anterior enclavation a 5.5\u0026ndash;5.7 mm posterior 3-stepped limbal wound was created with two adjacent paracentesis. Following instillation of viscoelastic, the lens was inserted and dialled being careful to maintain the correct vault. 2 x 10-nylon sutures added stability to the anterior chamber and the needle enclavation was performed once the lens was well-centred. A peripheral iridotomy was created where not already present. The wound was closed with interrupted 10-nylon sutures. With respect to posterior enclavation, the lens was inserted with the opposite vault and fixed sequentially to the posterior iris when the impression of the haptic visualised in the correct position.\u003c/p\u003e\u003cp\u003eThe study was approved by the hospital\u0026rsquo;s Clinical Audit and Effectiveness Committee as a comparison of best practice.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eMicrosoft Excel (Version 16.88) was used for data collection, and analysis was performed using SPSS Statistics (Version 29.0.2.0). This included descriptive statistics and paired samples t-testing to compare BCVA LogMAR values across different timepoints. A significance threshold was set at a p-value of less than 0.05.\u003c/p\u003e\u003cp\u003eVA was converted from Snellen to LogMAR using the formula provided by Tiew et al.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Snellen to LogMAR is converted as: counting fingers \u0026ndash; 1.87 LogMAR; hand motions \u0026ndash; 2.3 LogMAR; perception of light \u0026ndash; 3 LogMAR; and no perception of light \u0026ndash; 3.3 LogMAR.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eArtisan IOLs were implanted into 140 eyes (from 134 patients) between April 2015 and July 2024. The treatment group includes 82 male patients and 52 female patients, with an average age of 64.5 years (range: 19\u0026ndash;101; SD: 17.7 years). The indications for Artisan IOL insertion are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with the largest patient group being those left aphakic following complicated phacoemulsification (51 eyes; 37%) and patients with dislocated IOLs (39 eyes; 28%). Information on the specific indication could not be found for 3 eyes. The Artisan IOL was enclaved to the anterior iris in 123 eyes (88%) and posteriorly in 17 eyes (12%).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIndication for iris-claw IOL insertion\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplicated phacoemulsification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51 (37%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAphakic following retinal surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongenital cataracts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDislocated crystalline lens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (12%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDislocated IOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (28%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIOL opacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAny pre-existing ocular comorbidities prior to Artisan IOL implantation were recorded for all patients and are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. 67 eyes (48%) had one or more preexisting comorbidities; and 15 eyes (11%) had two or more. The most frequently occurring comorbidities recorded were retinal detachment (18 eyes; 22%), pseudoexfoliation syndrome (PXF) (8 eyes; 10%) and age-related macular degeneration (ARMD) (8 eyes; 10%).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOcular comorbidities prior to iris-claw IOL insertion\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetinal detachment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePseudoexfoliation syndrome (PXF)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eARMD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarfan's syndrome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmblyopia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHomocystinuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetic retinopathy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpiretinal membrane\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAphakia due to congenital cataracts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCMO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVitreous haemorrhage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorneal oedema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlaucoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOcular hypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetic macular oedema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStickler's syndrome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRVO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetinitis pigmentosa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGyrate atrophy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBacterial keratitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMacular hole\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePigment dispersion syndrome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAngle-closure glaucoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongenital glaucoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLASIK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e114 eyes had at least 6 months follow-up and were included in analysis of BCVA outcomes (see Fig.\u0026nbsp;1): the mean pre-operative BCVA was 1.13 logMAR (SD: 0.68 logMAR); mean 3-month BCVA was 0.58 logMAR (SD: 0.61 logMAR); and mean final BCVA was 0.47 logMAR (SD: 0.57 logMAR). Paired samples t-testing revealed statistically significant improvement in mean BCVA from the pre-operative timepoint to 3-months post-operatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and further significant improvement in BCVA from 3-month to final follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Overall, BCVA remained stable or improved in 107 (94%) eyes, and 7 (6%) eyes showed a worsening of BCVA (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients with worsening of VA at final follow-up\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVA pre-OP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVA final\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eComment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePenetrating eye injury by nail\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePenetrating eye injury with steel intraocular foreign body; lensectomy required\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStickler syndrome; corneal decompensation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEndophthalmitis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTrauma to eye; CMO\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePreexisting amblyopia and retinal detachment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA subgroup analysis of eyes treated with anterior vs. posterior iris enclavation showed a mean difference of 0.41 logMAR (95% CI: -0.15\u0026ndash;0.84 logMAR; p\u0026thinsp;=\u0026thinsp;0.029) favouring anterior enclavation. Further analysis for non-inferiority was not performed given the broad confidence interval, likely due to a limited number of cases included in the posterior enclavation group.\u003c/p\u003e\u003cp\u003eComplications were recorded as intraoperative, early post-operative (up to 30 days) and late. All intraoperative complications were associated with complex trauma cases and eyes with significant comorbidities (e.g. RD, Stickler syndrome), whereby no intraoperative complications occurred associated with Artisan insertion alone. 5 eyes presented with early post-operative complications: 2 cases of increased IOP (both resolving within 1 month); 1 case of uveitis (in an eye with known PXF); and 2 cases of corneal oedema (in 2 complex trauma cases).\u003c/p\u003e\u003cp\u003eThere were 22 cases of late-onset CMO: all uncomplicated cases resolved following a course of topical or injected steroids (sub-tenons or intraocular). Final visual acuity at 12 months was reduced in only one eye affected by CMO, and this case involved significant eye trauma. Artisan disenclavation occurred as a late complication in 4 eyes: in 2 cases this was associated with trauma to the orbit, and in all cases a corrective follow-up procedure was successful. There was a single case of late-onset post-surgical endophthalmitis in a patient who had undergone multiple previous ocular procedures resulting in no perception of light and phthisis of the affected eye. Retinal detachments occurred during the follow-up period in 3 patients, including 1 patient with previous retinal detachment. No convincing association with Artisan implantation was identified in any case. No patients developed post-operative hypotony, and no new incidence of glaucoma was seen following surgery.\u003c/p\u003e\u003cp\u003eOverall, 37 complications occurred with anterior iris enclavation (27% complication rate in this group), and 3 complications occurred following posterior enclavation (18% complication rate). Chi-squared comparison resulted in a value of 0.29 (p\u0026thinsp;=\u0026thinsp;0.59).\u003c/p\u003e\u003cp\u003eRefractive outcomes were available for a smaller subset of 48 eyes. The mean final refraction in dioptres was \u0026minus;\u0026thinsp;0.46 D (range: -5.5 to +\u0026thinsp;8.0 D; SD 1.97 D). 24 eyes (50%) achieved a final refraction within a range of -1 D to +\u0026thinsp;1 D.\u003c/p\u003e\u003cp\u003eInformation on the strength of Artisan lenses implanted (in dioptres) was available for 135 eyes. The mean lens strength was +\u0026thinsp;17.4 D (range: +6.0 D to +\u0026thinsp;27.0 D; SD: 4.2 D). Figure\u0026nbsp;1 shows the frequency of each strength of Artisan IOL inserted.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor aphakic patients, Artisan IOL insertion has become increasingly popular over the past decade, and has been demonstrated to be safe and effective in multiple studies[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The procedure is relatively less invasive compared to a scleral fixation approach, which is associated with an increased risk of choroidal haemorrhage and retinal detachment[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Angle-supported IOLs may be considered as an alternative, but carry their own risks of both secondary glaucoma and endothelial decompensation, and must be carefully sized to ensure an exact fit[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Artisan lenses offer the advantage of more flexibility in sizing as they are fixed to the mid-periphery of the iris. Furthermore, iris movements are largely unimpeded, facilitating iris dilation for ophthalmological examination or further surgery[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur data are derived from a large cohort of patients attending a quaternary referral centre in Dublin, Ireland, with many complex and chronic cases referred from other centres. We believe that this is the largest series currently in the literature examining this topic. This is reflected in the indications for Artisan insertion (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with 37% of patients being referred for Artisan implantation following complicated phacoemulsification. In the majority of these cases, patients were left aphakic following initial surgery to await a secondary Artisan procedure. Our data on preexisting ocular comorbidities also paint a picture of a complex and multimorbid group, with almost half of the eyes analysed being associated with at least one preexisting ocular condition.\u003c/p\u003e\u003cp\u003eDespite this challenging cohort, we report positive BCVA outcomes in line with other studies involving complex patient groups[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Of the small group of 7 eyes with a BCVA which worsened from pre-treatment to final follow-up, 4 eyes represented complex ocular trauma cases. A further two cases had significant ocular comorbidities: Stickler syndrome; and a previous retinal detachment. The remaining patient had a history of multiple surgeries on the affected eye, including Artisan IOL implantation, resulting in post-operative endophthalmitis and secondary phthisis.\u003c/p\u003e\u003cp\u003eIt is interesting to note the modest, but significant, further improvements seen in BCVA from 3 months to 12 months post-operatively. It is at around 3 months that patients return for a follow-up appointment for removal of corneal sutures placed intraoperatively. The further improvements to BCVA beyond 3 months are likely therefore to be explained by resolution of astigmatism, as shown previously[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Beyond 6 months, BCVA tends to remain stable provided no complications occur, and this was reflected in our data.\u003c/p\u003e\u003cp\u003eIn recent years, Artisan lenses are more frequently being implanted in the retropupillary location \u0026ndash; enclaved to the posterior iris \u0026ndash; offering the optical advantages of an IOL positioned in the posterior chamber, combined with a relatively straightforward procedure which can be carried out via corneal incisions[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our own anterior versus retropupillary comparison of BCVA outcomes were similar between groups. An advantage of posterior implantation is that IOLs implanted anterior to the iris are at greater risk of exposing the corneal endothelium to mechanical effects, leading to reduced endothelial cell counts and potential additional complications due to corneal decompensation[\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our analysis 5 cases of corneal decompensation were identified, all occurring with anterior iris enclavation and none in posterior placement. Whilst not significant, our work is supportive of the less traumatic nature of retropupillary placement.\u003c/p\u003e\u003cp\u003eAnalysis of refractive outcomes in a subgroup of patients provides some evidence of satisfactory refractive results, whereby half of eyes had a final refraction between +\u0026thinsp;1D and \u0026minus;\u0026thinsp;1D. Given that target final refraction is oriented on patient preference (i.e. target for reading, mid, or distance vision) some variation in final refraction is to be expected. Although it was not possible to collect data for refractive results for the majority of patients in our study, it was our experience that most patients were satisfied with the final refractive results.\u003c/p\u003e\u003cp\u003eIn our study, we were able to collect comprehensive information of the strength of Artisan IOLs implanted in every eye. This has allowed us to report on the most commonly used prescriptions to guide other centres in their ordering of lenses to be stocked in-house. The alternative \u0026ndash; case-by-case lens ordering \u0026ndash; is cumbersome, leading to treatment delays and often not allowing contemporaneous placement of this lens due to unavailability. Despite the clear advantages of an in-house lens bank, it can be difficult to target ordering to ensure the right stock levels. Our centre maintains a stock of lenses in the range of +\u0026thinsp;6.0D to +\u0026thinsp;27D, in 0.5D increments. Depending on case volumes at each centre, our data indicate that a sensible strategy could be to stock more than 1 unit within the range of +\u0026thinsp;14.0D to +\u0026thinsp;24.0D, and certainly to do so at the peak frequencies between +\u0026thinsp;17.0D and +\u0026thinsp;20.0D.\u003c/p\u003e\u003cp\u003eThe major limitations of this study are its retrospective design. Follow-up data for some patients was unavailable, often as they were followed up externally. A limited sample size of eyes in the posterior-iris enclavation group made meaningful comparison between anterior and posterior iris-enclavation approaches difficult, and a future study including a greater number of eyes with retropupillary Artisan IOLs would help clarify the efficacy of this emerging surgical approach.\u003c/p\u003e\u003cp\u003eIn conclusion, our study provides further evidence of the safety and efficacy of Artisan IOL implantation even in a complex comorbid cohort of aphakic patients with inadequate capsular support. Insights provided into lens strengths used in our large sample will be of great practical benefit to other centres establishing lens banks in order to optimise lens ordering. Further evidence is however required regarding the best option for iris enclavation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003eThe study adhered to the Declaration of Helsinki and ethical standards for human research.\u003c/li\u003e\n \u003cli\u003eEthical approval was granted by the Clinical Audit and Effectiveness Committee of the Mater Misericordiae University Hospital.\u003c/li\u003e\n \u003cli\u003eInformed consent was waived due to the retrospective, anonymised nature of the data.\u003c/li\u003e\n \u003cli\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis research received no specific grant from any funding agency, commercial, or not-for-profit sectors. No external sources of material or financial support were provided.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Robert Castledine and Luke O\u0026rsquo;Brien. The first draft of the manuscript was written by Robert Castledine and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTiew S, Lim C, Sivagnanasithiyar T. Using an excel spreadsheet to convert Snellen visual acuity to LogMAR visual acuity. Eye (Lond). 2020;34(11):2148-9.\u003c/li\u003e\n\u003cli\u003eNegretti GS, Chan WO, Muqit MMK. Artisan iris-claw intraocular lens implantation in vitrectomised eyes. Eye (Lond). 2021;35(5):1393-7.\u003c/li\u003e\n\u003cli\u003eChen Y, Liu Q, Xue C, Huang Z, Chen Y. Three-year follow-up of secondary anterior iris fixation of an aphakic intraocular lens to correct aphakia. J Cataract Refract Surg. 2012;38(9):1595-601.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;ell JL, Verdaguer P, Elies D, Gris O, Manero F, Mateu-Figueras G, et al. Secondary iris-claw anterior chamber lens implantation in patients with aphakia without capsular support. Br J Ophthalmol. 2014;98(5):658-63.\u003c/li\u003e\n\u003cli\u003eBellucci R, Pucci V, Morselli S, Bonomi L. Secondary implantation of angle-supported anterior chamber and scleral-fixated posterior chamber intraocular lenses. Journal of Cataract \u0026amp; Refractive Surgery. 1996;22(2):247-52.\u003c/li\u003e\n\u003cli\u003eZeh WG, Price FW, Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 2000;26(7):1028-34.\u003c/li\u003e\n\u003cli\u003eHennig A, Johnson GJ, Evans JR, Lagnado R, Poulson A, Pradhan D, et al. Long term clinical outcome of a randomised controlled trial of anterior chamber lenses after high volume intracapsular cataract surgery. Br J Ophthalmol. 2001;85(1):11-7.\u003c/li\u003e\n\u003cli\u003eLett KS, Chaudhuri PR. Visual outcomes following Artisan aphakia iris claw lens implantation. Eye (Lond). 2011;25(1):73-6.\u003c/li\u003e\n\u003cli\u003eNegretti GS, Chan WO, Pavesio C, Muqit MMK. Artisan-style iris-claw intraocular lens implantation in patients with uveitis. J Cataract Refract Surg. 2019;45(11):1645-9.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;ell JL, Velasco F, Malecaze F, V\u0026aacute;zquez M, Gris O, Manero F. Secondary Artisan-Verysise aphakic lens implantation. J Cataract Refract Surg. 2005;31(12):2266-71.\u003c/li\u003e\n\u003cli\u003ePotamitis T, Fouladi M, Eperjese F, McDonnell PJ. Astigmatism decay immediately following suture removal. Eye (Lond). 1997;11 ( Pt 1):84-6.\u003c/li\u003e\n\u003cli\u003eDrolsum L, Kristianslund O. Implantation of retropupillary iris-claw lenses: A review on surgical management and outcomes. Acta Ophthalmol. 2021;99(8):826-36.\u003c/li\u003e\n\u003cli\u003eKim M, Kim JK, Lee HK. Corneal endothelial decompensation after iris-claw phakic intraocular lens implantation. J Cataract Refract Surg. 2008;34(3):517-9.\u003c/li\u003e\n\u003cli\u003evan Eijden R, de Vries NE, Cruysberg LP, Webers CA, Berenschot T, Nuijts RM. Case of late-onset corneal decompensation after iris-fixated phakic intraocular lens implantation. J Cataract Refract Surg. 2009;35(4):774-7.\u003c/li\u003e\n\u003cli\u003eSchallenberg M, Dekowski D, Hahn A, Laube T, Steuhl KP, Meller D. Aphakia correction with retropupillary fixated iris-claw lens (Artisan) - long-term results. Clin Ophthalmol. 2014;8:137-41.\u003c/li\u003e\n\u003cli\u003eForlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmol. 2015;15:143.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Iris-claw IOL, Artisan, aphakia, retropupillary","lastPublishedDoi":"10.21203/rs.3.rs-7798031/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7798031/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: To examine the outcomes and complication rates of iris-claw intraocular lens (IOL) implantation in an aphakic cohort, with a comparison of anterior versus retropupillary enclavation, and an analysis of the biometric spread of implanted IOLs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: In this single-centre retrospective case series, we analysed the medical records of 140 eyes from 134 patients who underwent iris-claw IOL implantation between April 2015 and July 2024. Analysis included patient demographics, surgical approach (anterior vs. retropupillary), lens strength, and both intraoperative and postoperative outcomes. Best-corrected visual acuity (BCVA) was evaluated preoperatively, at 3 months, and at 6–12 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The mean preoperative BCVA was 1.13 logMAR, which improved to 0.47 logMAR at final follow-up (p \u0026lt; 0.001), with 94% of eyes achieving stable or improved vision. The difference in complication rates between anterior (27%) and posterior (18%) enclavation was not statistically significant (p = 0.59). Corneal decompensation only occurred in cases of anterior iris enclavation. Cystoid macular oedema (CMO) occurred in 22 eyes, with all uncomplicated cases resolving with steroid treatment. Late disenclavation of the IOL was a rare complication. Half of the patients achieved a final refraction within ±1D of target. The most commonly implanted lens strengths ranged between +17.0D and +20.0D.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Iris-claw IOL implantation is a safe, effective option for aphakic patients lacking capsular support, even in a complex comorbid patient cohort. Our findings suggest that retropupillary placement may be a less traumatic alternative to anterior enclavation, though further evidence is needed.\u003c/p\u003e","manuscriptTitle":"Clinical Insights into Iris-Claw IOLs in Aphakic Patients at a Tertiary Referral Centre","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:10:03","doi":"10.21203/rs.3.rs-7798031/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1673b34c-8f96-4a44-a573-d3c4b3ca2f8a","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-17T18:38:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 04:10:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7798031","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7798031","identity":"rs-7798031","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}