Visual outcome, safety, and complications of iris suture fixation versus iris claw fixation for aphakic correction: a prospective randomized study

This study aimed to compare visual outcomes, safety profiles, and complication rates between retropupillary iris claw fixation and iris suture fixation of posterior chamber intraocular lenses (IOLs) in aphakic eyes lacking sufficient capsular support. This prospective randomized controlled trial enrolled 50 aphakic eyes from 50 patients, equally allocated to iris claw fixation (n = 25) or iris suture fixation (n = 25). The primary outcome was corrected distance visual acuity (CDVA) at 12 months. Secondary outcomes included surgical duration, IOL decentration and tilt, intraocular pressure (IOP), cystoid macular edema (CME), endothelial cell density loss, and other postoperative complications. Evaluations were performed at 1, 3, 6, and 12 months postoperatively. Both techniques yielded statistically significant CDVA improvement from baseline (p < 0.001). Mean surgical duration was significantly shorter in the iris-claw group (30.5 ± 3.2 min) compared with the iris-suture group (46.4 ± 4.5 min; p < 0.001) reflecting the greater technical complexity of suture-based fixation. Regarding cost, no formal economic analysis was performed; however, while iris-claw lenses are specialized and iris-suture fixation requires 10 − 0 Prolene, both techniques use readily available surgical materials, and the overall difference in procedural cost is expected to be modest. The iris claw group demonstrated superior early visual recovery at 1 and 3 months; however, CDVA converged between groups by 12 months (0.10 ± 0.10 vs. 0.12 ± 0.10 logMAR; p = 0.23). Refractive outcomes modestly favored iris claw fixation, with lower mean spherical equivalent (− 0.30 ± 0.40 diopters vs. −0.50 ± 0.50 diopters; p = 0.08) and reduced residual astigmatism (− 0.85 ± 0.61 diopters vs. −1.21 ± 0.74 diopters; p = 0.04). IOP, central corneal thickness, and macular thickness remained stable throughout follow-up in both cohorts. Complication rates were low: disenclavation occurred in one eye (4%) in the iris-claw group, mild suture erosion in two eyes (8%) in the iris-suture group, and transient anterior chamber inflammation in three eyes (12%) and four eyes (16%), respectively. Endothelial cell loss was significantly greater in the iris claw group (14.5% vs. 9.8%; p < 0.001). Retropupillary iris claw and iris suture fixation both provide effective and safe options for secondary IOL implantation in aphakic eyes without capsular support. Iris claw fixation facilitates faster early visual rehabilitation and marginally better refractive predictability, whereas iris suture fixation may be preferable in eyes with preexisting endothelial compromise. Surgical technique selection should be individualized based on ocular comorbidities and the surgeon’s expertise. Retrospectively registered at ClinicalTrials.gov; registration number: NCT06933654; registered on 11 April 2025.