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.