Secondary retropupillary iris-claw intraocular lens implantation in eyes with low corneal endothelial reserve: A retrospective cohort study

Purpose: The aim of this article is to evaluate the safety and visual outcomes of secondary retropupillary iris-claw intraocular lens (ICIOL) implantation in aphakic eyes with reduced corneal endothelial cell density (ECD <1000 cells/mm 2 ). Methods: A retrospective analysis was conducted on patients undergoing secondary retropupillary ICIOL fixation in eyes with low corneal endothelial reserve between June 2022 and December 2024. Pre- and postoperative parameters included uncorrected distance visual acuity (UDVA), corneal endothelial indices (ECD, coefficient variation CV, hexagonality percentage HEX, and corneal thickness CT), and complication rates were assessed. Statistical analysis was performed using repeated-measures analysis of variance and Wilcoxon signed-rank tests. Results: Twenty-seven eyes of 27 patients were included, with a mean follow-up duration of 17.93 ± 13.72 months (range 6–48 months). The primary cataract surgery included phacoemulsification ( n = 19) as well as manual small incision cataract surgery ( n = 8). Mean UDVA improved significantly from 1.04 ± 0.25 to 0.13 ± 0.14 logMAR at final follow-up ( P < 0.001). Endothelial structural parameters demonstrated no statistically significant difference postoperatively. The mean ECD was 758.1 ± 160.9 cells/mm 2 ² preoperatively and 716.2 ± 124.7 cells/mm 2 ² postoperatively at the final follow-up ( P = 0.84). The mean CV was 36.7% ± 11.1% preoperatively and 34.8% ± 9.2% postoperatively ( P = 0.78), whereas the HEX was 51.3% ± 9.2% preoperatively and 47.4% ± 8.6% at the final follow-up ( P = 0.43). The pre-operative and postoperative CT values were 568.9 ± 71.6 µm and 573.1 ± 60.4 µm, respectively ( P = 0.94). No evidence of bullous keratopathy, persistent inflammation, or ICIOL disenclavation was observed. Conclusion: Retropupillary ICIOL implantation is a safe and effective surgical option for aphakic eyes with compromised corneal endothelial reserve. Its technical simplicity, minimal manipulation, and reproducibility make it a reliable approach in eyes with low corneal ECD.