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Abstract

Background:

Moderate-to-severe lens subluxation poses surgical challenges due to extensive zonular weakness and the need to maintain stable intraocular lens (IOL) positioning while preserving the capsular bag.

Objectives:

To evaluate the outcomes and safety of a modified technique using intrascleral suture fixation of a standard capsular tension ring (CTR) to preserve the capsular bag in moderate-to-severe lens subluxation.

Design:

Retrospective, single-center case series.

Methods:

Consecutive eyes with 120°–300° zonular dialysis underwent phacoemulsification via a 2.4 mm clear corneal incision and a 0.8 mm lateral incision. Capsular bag stabilization was achieved by intrascleral fixation of a standard CTR using a knotless Z-suture with double-strand 8–0/9-0 polypropylene, followed by in-the-bag IOL implantation. Primary outcomes were postoperative IOL centration and corrected-distance visual acuity (CDVA); secondary outcomes included refractive error and complications. Follow-up was scheduled at 1, 3, 6 months (some at 12 months) and annually thereafter.

Results:

Sixteen eyes of nine patients were included. Median follow-up was 328.0 days (interquartile range (IQR) 256.5, 443.0). Median logMAR CDVA improved from 0.35 (IQR 0.30, 0.57) preoperatively to 0.19 postoperatively. Mean absolute spherical equivalent decreased from 9.82 ± 1.02 D to 1.16 ± 0.25 D. IOLs were well‑centered in 13 eyes (81.3%); a slight, clinically insignificant tilt was observed in 3 eyes (18.7%). One intraoperative posterior capsule rupture did not preclude in-the-bag IOL implantation. Two eyes had transient postoperative intraocular pressure elevation managed medically. No other significant complications occurred.

Conclusion:

Intrascleral fixation of a standard CTR is a simple, accessible, and effective bag-preserving technique for moderate-to-severe lens subluxation, enabling stable in-the-bag IOL implantation with favorable visual and refractive outcomes.

Registration:

ClinicalTrials.gov: NCT06627062.

Plain language summary

This technique offers a simplified, cost-effective solution for complex lens subluxation cases, making it accessible even in resource-limited settings. It provides a reliable approach for maintaining IOL alignment and improving surgical outcomes, with potential for broader clinical adoption in diverse healthcare environments.

This study introduces a simple and effective surgical technique for patients with severely dislocated lenses, known as “subluxation.” This condition occurs when the lens in the eye shifts from its usual position, causing vision problems. The new method involves using a standard capsular tension ring (CTR), a small device that helps stabilize the lens, along with a special type of suture (a surgical thread) to fix the ring in place within the eye. The technique was tested on 16 eyes of 9 patients, most of whom had congenital lens dislocation. The results were promising: all patients had successful lens implantations, and their vision improved after surgery. No serious complications were observed, and the eye’s structure remained stable after the operation. The method was particularly useful for patients with large dislocations, where traditional methods might not work as well. This new technique is easier to perform than other more complicated methods, and it doesn’t require specialized equipment that may not be available in all places. It provides a reliable option for doctors to treat patients with severe lens dislocations, particularly in countries where advanced devices are difficult to access. Further studies are needed to confirm the long-term effectiveness of this approach.

Keywords

capsular bag capsular tension ring intrascleral fixation subluxated lens surgical technique

Introduction

Lens subluxation, the displacement of the crystalline lens from its normal anatomical position due to weakened or broken zonular fibers, can arise from various etiologies including trauma, inherited disorders such as Marfan syndrome, or systemic diseases.¹ Its severity is graded based on the proportion of the pupil area uncovered by the lens after mydriasis: mild (0%–25%), moderate (25%–50%), and severe (>50%).¹ In moderate-to-severe cases, patients often experience progressive blurred vision, monocular diplopia, or secondary angle-closure glaucoma, highlighting the need for effective surgical intervention.²

Surgical management aims to remove the subluxated lens and achieve stable intraocular lens (IOL) placement within the capsular bag, which acts as a natural barrier against complications such as glaucoma, optic capture, and retinal detachment.^3,4 To address this challenge, a variety of surgical strategies have been developed.^5–7 For mild cases with less than 120° of zonular weakness, a standard capsular tension ring (CTR) is often sufficient to expand the capsular bag and distribute forces evenly.^8,9 In cases of moderate-to-severe subluxation or progressive pathologies—such as Marfan syndrome, Weill-Marchesani syndrome, or high myopia—a standard CTR alone cannot provide centration or prevent progressive decentration, necessitating scleral fixation with specialized devices like a capsular tension segment (CTS), a modified CTR (m-CTR), or other specialized devices.^9–11 However, these advanced devices are not universally available and can be prohibitively expensive in many countries, creating a compelling clinical need for innovative techniques that leverage common tools, such as the standard CTR, to manage moderate-to-severe cases while preserving the capsular bag. The core principle of the technique presented in this study is to overcome this limitation by augmenting a standard CTR with scleral suture fixation, thereby providing an active centration force that is functionally analogous to that of a specialized, predesigned fixation ring.

In recent years, innovative approaches such as flanged intrascleral IOL fixation have become widespread for managing aphakia or IOL dislocation.¹² Several new techniques have emerged focusing on securing the native capsular bag, including the “Lord of the Ring” technique and various methods for scleral fixation of a standard CTR.^13,14 For instance, novel techniques such as the four-flanged 6-0 polypropylene suture method for scleral IOL fixation, as described by Lcoz et al.,¹⁰ exemplify the current movement toward creative, knotless approaches that provide robust stability without the risks of suture erosion. This broader context underscores the ongoing search for simpler, safer, and more effective methods for securing implants in the absence of adequate zonular support.

While specialized devices are effective, their availability and cost can be limited. Techniques that sacrifice the capsular bag, though valuable, abandon the physiological barrier it provides. Therefore, developing simple, reproducible, and cost-effective methods to secure a standard CTR and preserve the capsular bag remains a significant goal. The purpose of this study was to evaluate the clinical outcomes and safety of a modified technique for intrascleral fixation of a standard CTR in patients with moderate and severe subluxated lens extraction ranging between 120° and 300°. We hypothesized that this approach would provide stable, long-term IOL centration and excellent visual rehabilitation with a low rate of complications.

Material and methods

Participants

Inclusion criteria were: (1) Consecutive patients attending the ophthalmology clinic at the Eye and ENT Hospital of Fudan University, Shanghai, China, between January 2023 and December 2024; (2) Patients with moderate-to-severe lens subluxation (defined as zonular dialysis of 120°–300°) who underwent intrascleral fixation of standard capsular tension ring; (3) a minimum follow-up period is greater than 6 months. Exclusion criteria included: (1) corneal opacities obscuring the view; (2) history of previous intraocular surgery. A total of 16 eyes from 9 patients were included. All participants were provided with written informed consent detailing the possible risks and benefits of this treatment. All surgeries were performed at the Affiliated Eye & ENT Hospital of Fudan University.

Preoperative and postoperative assessment

All patients underwent a comprehensive ophthalmological examination preoperatively and at 1, 3, 6 months postoperatively, some at 12 months, and annually thereafter. The examination included: corrected-distance visual acuity (CDVA), intraocular pressure (IOP), anterior chamber depth, extent of ectopia lentis by slit-lamp biomicroscopy and UBM (MD-300 L, MEDA, Tianjin, China), B-scan ultrasonography, optical coherence tomography (OCT5000, Carl Zeiss Meditec, Inc., Dublin, CA, USA), corneal endothelium cell density, and fundus examination. Postoperative refraction, including spherical and cylindrical values, was recorded.

Postoperative medication followed a standard regimen for cataract surgery, typically consisting of topical antibiotics and steroids for 4 weeks.

Surgical technique

All procedures were performed by a single, experienced surgeon (Y.H.J) under peribulbar or general anesthesia on patients with moderate-to-severe lens subluxation (120–300° of zonular dialysis). A 2.4 mm clear corneal incision and a 0.8 mm lateral incision were created. An ophthalmic viscosurgical device (OVD) was injected intracamerally to enable anterior to continuous curvilinear capsulorhexis (CCC) (Figure 1(a)). To stabilize the capsular bag, temporary capsular hooks (CapsuleCare; Med Devices Lifesciences) were placed at the side of zonular dialysis (Figure 1(b)). Phacoemulsification was then performed in conjunction with a phaco-and-chop technique by the Centurion^® Vision System (Alcon Laboratories Inc., USA) (Figure 1(c)). Prior to withdrawing the ultrasonic phacoemulsification and aspiration needle, the OVD was reinjected to maintain the anterior chamber and capsular bag.

Figure 1.

Intraoperative steps of the intrascleral fixation of the capsular tension ring for a case of Marfan syndrome with severe subluxation lens. (a) Capsulorhexis; (b) Fixation of the dislocated capsule with the temporary capsular hooks; (c) Ultrasonic emulsification and aspiration; (d) Double-strand 9-0 polypropylene suture was tied to one end of the preloaded standard CTR using a looping technique; (e) CTR implantation; (f) CTR suspension to the sclera in the same quadrant of the zonular weakness; (g) IOL implantation; (h) IA; (i) close the incisions and suture the conjunctival Flap.

A double-strand polypropylene suture with a curved long needle (9-0 POLYPROPYLENE 20 cm LOOP, 2452L, MANI, INC., Japan) or (8-0 Prolene, Ethicon, Johnson and Johnson, USA) was tied to one end of the standard preloaded CTR using a looping technique, then preloaded CTR was retracted into the inserter immediately after suturing (Figure 1(d)). The suture was gently tugged to ascertain its secure attachment to the CTR, taking precautions to prevent any knots or twists. Using the preset suture, the CTR was implanted into the capsule and adjusted to place the suture in the middle of the lens displacement (Figure 1(e)). A temporary capsular hook (or hooks) provided countertraction to the bag and enabled easy rotation of the ring into the bag during this stage. The needle was inserted through the main incision after the temporary capsular hook(s) were removed. Through the anterior chamber of the eye, under the posterior surface of the iris, then through the layers of the scleral wall, it exits 2.0 mm posterior to the limbus at the central area of zonular dialysis (Figure 1(f)). The needle was threaded through the interlamellar sclera using a knotless Z-suture technique, and the polypropylene suture was adjusted for tension and centered using a needle holder or forceps. Following stabilization, a foldable one-piece hydrophobic acrylic IOL (Tecnis PCB00; Abbott Medical Optics) was implanted into the capsular bag (Figure 1(g)). The OVD and any residual cortex were removed with coaxial irrigation/aspiration (Figure 1(h)). The corneal incision was closed with a 10-0 nylon suture, and the conjunctival flap was repositioned and secured with an 8-0 Vicryl suture (Figure 1(i)).

The decision to use single-point scleral fixation (for subluxation ranging from 120° to 225°) or two-point scleral fixation (for subluxation ranging from 225° to 300°) during the surgery was dependent on the extent of the lens ectopia. The single fixation point was positioned at the center of the area of weakened or disinserted zonules. In two-point fixation, the two points were placed at positions 90° superior and inferior (or left and right) to the center of the area of zonular dialysis, respectively. These two points provided balanced support for the capsular bag, creating a line of tension along an axis of almost 180° (See Figures 1 and 2, and Supplemental Digital Video 1 for intraoperative steps).

Figure 2.

Preparation Procedure for scleral-fixated standard preloaded CTR. (a) Double-strand polypropylene suture was tied to one end of the preloaded standard CTR using a looping technique; (b) Tug the suture to ensure its secure attachment to the CTR. Black arrow: knot at the fixation point. (c) Preloaded CTR was retracted into the inserter immediately after suturing. (d) Preloaded CTR was implanted into the capsular bag through the main incision. (e) The suture was adjusted toward the middle of the lens dislocation. (f) Single-point scleral fixation (for subluxation ranging from 120° to 225°), (g) two-point scleral fixation (for subluxation ranging from 225° to 300°). It passed through the anterior chamber, under the posterior iris surface, then through the scleral wall, exiting 2.0 mm posterior to the limbus at the central area of zonular weakness. The tension of the polypropylene suture was adjusted to center the capsular bag, and the CTR was sutured to the sclera with the modified knotless Z-suture technique.

For the majority of cases requiring single-point fixation, the average surgical time was approximately 25–35 min. For the complex case that required two-point fixation (i.e., the 300° dialysis case), the surgical time was approximately 45 min.

Outcome measures

Preoperative data collection included etiology, patient age, sex, CDVA, axial length (AL), white-to-white (WTW) distance, and spherical equivalent (SE). The primary outcomes were postoperative CDVA and IOL centration assessed by slit-lamp biomicroscopy. Secondary outcomes included postoperative SE and the incidence of intraoperative and postoperative complications.

Statistical analysis

Statistical analysis was performed using SPSS version 25.0. Snellen CDVA was converted to logMAR for analysis. Due to the data distribution, medians and interquartile ranges (IQR) were used for patient age, CDVA, and follow-up time. Means and standard deviations (±SD) were used for other parameters. The Wilcoxon signed-rank test was used to compare preoperative and postoperative CDVA. A p-value of <0.05 was considered statistically significant.

This retrospective case series was prepared in accordance with the PROCESS 2020 guideline for surgical case series and the STROBE statement for observational studies; completed checklists are provided in the Supplemental Materials (Files S1–S2).

Results

The technique was used in 16 eyes of 9 patients (3 females and 6 males). The cohort included 15 eyes with congenital lens subluxation and 1 eye with traumatic subluxation, with a subluxation range between 120° and 300° (Table 1).

Table 1.

Demographic data of all patients.

Parameters	Value
Patient/ eyes No. (R/L)	9/16 (8/8)
Sex (Female/Male)	3/6
Mean ± SD
Preoperative absolute SE	9.82 ± 1.02
Postoperative absolute SE	1.16 ± 0.25
WTW	12.11 ± 0.14
Median (interquartile range)
Age, year	10.5 (6.0, 15.0)
AL	24.88 (22.17, 28.04)
Preoperative CDVA (logMAR)	0.35 (0.30, 0.57)
Postoperative CDVA (logMAR)	0.19 (0.10, 0.30)
Follow-up Time (days)	328.0 (256.5, 443.0)
Diagnosis (eyes)	Congenial (15) Traumatic (1)

Normally distributed data were shown in the mean + standard deviation and were shown in median (interquartile range) otherwise.

AL, axial length; CDVA, corrected-distance visual acuity; L, left; logMAR, logarithm of the minimum angle of resolution; No., number; R, right; SD, standard deviation; SE, spherical equivalent; WTW, white to white.

The median patient age at the time of surgery was 10.5 years (IQR 6.0, 15.0). Preoperative baseline characteristics were as follows: the median AL was 24.88 mm (IQR 22.17, 28.04), and the mean white-to-white distance was 12.11 ± 0.14 mm. The preoperative median logMAR CDVA was 0.35 (IQR 0.30, 0.57), and the preoperative mean absolute SE was 9.82 ± 1.02 D.

Regarding the surgical procedure, 15 eyes were stabilized with a single fixation suture, while 1 eye with a severe, approximately 300-degree dislocation required two-point fixation. Concomitant anterior vitrectomy was performed in two eyes. There was one instance of intraoperative posterior capsule rupture; however, the small tear did not hinder the implantation of the IOL within the capsular bag. No other significant intraoperative complications were observed.

The median postoperative follow-up time was 328.0 days (IQR 256.5, 443.0). A significant improvement was observed in visual acuity, with the postoperative median logMAR CDVA decreasing to 0.19. A significant reduction in refractive error was also achieved, with the mean absolute SE decreasing to 1.16 ± 0.25 D).

During the follow-up period, the IOLs remained well-centered in 13 eyes (81.3%) (Figure 3); however, a slight, clinically insignificant tilt of the IOL was observed in 3 eyes (18.7%) (Figure 4). In all cases, adequate capsular tension was observed, evidenced by the slight enlargement and circular deformation of the capsulorhexis rim by the holding forces (Figure 5). There were no signs of erosion or exposure of the polypropylene suture knot. Two cases experienced a transient increase in intraocular pressure within a week of surgery, which resolved with topical anti-glaucoma medication. No other postoperative complications, such as hypotony, hyphema, pupil deformation, cystoid macular edema, vitreous hemorrhage, or retinal detachment, occurred.

Figure 3.

Anterior segment photography and anterior segment Optical Coherence Tomography (OCT) after surgical treatment of a case of traumatic lens subluxation with a 180-degree disinsertion. (a) Anterior segment photography of the right eye; (b) Anterior segment OCT showing the intraocular lens in the right position.

Figure 4.

Anterior segment photography and anterior segment OCT after surgical treatment of a case of MFS with a 270-degree disinsertion. (a) Anterior segment photography of the left eye; (b) Anterior segment OCT showing a slight tilt of the intraocular lens.

Figure 5.

Eye of MFS with a 160-degree disinsertion. A. Preoperative anterior segment photograph. B. One-month postoperative anterior segment photograph. White arrow: the fixation site of the standard CTR. Adequate tensions provided by the CTR scleral fixation could be observed because the CCC rim is slightly enlarged and deformed by the holding forces. IOL donesis is not observed.

Discussion

The central finding of our study is that a CTR, when augmented by scleral fixation, can be safely and effectively used to manage moderate-to-severe lens subluxation. We concur with the established principle that a standard CTR alone is insufficient for dialysis exceeding 120°, as it cannot independently provide centration.^8,15 Our modification functionally transforms this widely available device into a bag-stabilizing system: a double-strand 8-0 or 9-0 polypropylene suture provides a direct scleral anchor opposite the zonular deficit, generating active countertraction that maintains long-term centration of the entire capsular bag-IOL complex. Mechanistically, this is analogous to a modified CTR (m-CTR) or a CTS, but relies on readily accessible materials. This is particularly relevant where specialized devices (m-CTR, CTS, Assia Anchor) may be restricted by cost, regulation, or supply.

Advantages of preserving the native capsular bag

By suturing a standard CTR to the sclera, our technique restores equatorial capsular tension while preserving the native capsular diaphragm. Functionally, this isolates the anterior and posterior segments and stabilizes the anterior hyaloid face, which may reduce long-term risks such as iris chafe, pigment dispersion, and secondary glaucoma. In our series, these physiologic advantages translated into stable centration in most eyes (81.3%) and only slight, clinically insignificant tilt in the remainder (18.7%), alongside improvements in CDVA (median logMAR from 0.35 to 0.19) and refractive error (mean absolute SE from 9.82 ± 1.02 D to 1.16 ± 0.25 D). Taken together, preserving the bag provides a stable in-the-bag platform for the IOL and maintains the eye’s natural anatomic barrier, which we believe contributes to sustained centration and optical quality over time.

Technique selection relative to capsular bag-preserving

When capsular bag integrity is salvageable, a bag-preserving approach (as described here) leverages the physiologic barrier and equatorial support. When the capsule is nonviable, flanged intrascleral IOL fixation (e.g., the Yamane technique) is indispensable.¹² In gray-zone cases where zonular weakness is too advanced for safe CTR insertion but the capsular bag remains structurally intact, bag-preserving Yamane variants have been reported: the IOL is fixated by flanged intrascleral haptic fixation while the native capsule is left in situ as a physiologic diaphragm.¹⁶ These approaches can, in selected eyes, avoid pars plana vitrectomy and provide sutureless, stable fixation, but they require a 3-piece IOL and precise haptic externalization with symmetric flange creation.¹⁷ By contrast, our CTR-suturing method reconstitutes circumferential equatorial tension with ubiquitous materials (standard CTR plus polypropylene), directly stabilizing the bag-IOL complex and potentially mitigating late decentration driven by capsular equator instability. Technique selection should be individualized: bag‑preserving Yamane approaches are advantageous when CTR insertion is unsafe despite an intact capsule, whereas our CTR‑suturing method is preferred when the capsule is fragile but salvageable and a CTR can be safely seated and fixated.

Comparison with other stabilization strategies

Preserving the capsular bag is a shared goal of several modern fixation strategies.^7,18,19 Modified CTRs, such as the Cionni ring, simplify scleral fixation by providing eyelets, yet these are specialized and may be costly or unavailable in many settings.⁶ Our method leverages a ubiquitous standard CTR to achieve a similar stabilizing effect. In contrast, directly suturing IOL haptics to the sclera secures the IOL but does not address capsular equator instability, leaving the bag susceptible to fibrotic contraction and late decentration of the bag-IOL complex.²⁰ Suturing the CTR itself restores circumferential equatorial tension, provides a stable in-the-bag platform for the IOL, and maintains the natural capsular architecture—factors that may contribute to long-term centration and stability.

Suture choice and fixation security

Reports of late spontaneous rupture of 10-0 polypropylene sutures have informed a trend toward thicker materials for long-term scleral fixation.²¹ Accordingly, we used 8-0 or 9-0 polypropylene as an on-label, durable alternative; some surgeons prefer off-label 7-0 Gore-Tex for its strength. Larger knots can predispose to scleral/conjunctival erosion with a theoretical risk of infection; to mitigate this, we adopted a knotless Z-suture that buries suture ends within an interlamellar scleral path, obviating scleral flaps and reducing late knot‑related complications.

Practical considerations

Our results support the efficacy of this adaptive strategy. The fact that 15 of 16 eyes (94%) were stabilized with a single fixation point underscores the principle that minimalist intervention is often sufficient. The single case requiring two-point fixation validates the versatility of the technique, demonstrating its capacity to manage even the most severe forms of dialysis (the recommended subluxation range is 225°–300°). While this technique is straightforward in concept, its execution involves several technical challenges, for which we offer the following tips and precautions: (1) When implanting the CTR, directing it toward the weak zonules reduces tension on the zonules; (2) Using the temporary capsular hooks during surgery can effectively pull the capsular opening, fix and support the dislocated capsular bag, significantly reducing pressure on the weak zonules and protecting the anterior capsular opening from tearing; (3) If vitreous prolapse into the pupillary area or anterior chamber occurs, anterior vitrectomy can be performed.

Limitations

Despite these promising results, this study has limitations. First, as a retrospective series, it includes a relatively small sample size without a formal power Sample Size calculation, and the follow-up duration is insufficient to draw definitive conclusions about the long-term outcomes of the suture fixation. This leads directly to the primary inherent limitation of the technique itself: the long-term integrity of the suture. Although we used a more durable 8-0 or 9-0 polypropylene suture, late degradation and breakage, leading to redislocation of the capsular bag-IOL complex, remains a long-term challenge for all scleral fixation techniques. Second, suture-related complications, such as conjunctival erosion over the suture knot or subsequent endophthalmitis, while not observed in our series, remain a potential risk for this type of procedure. Furthermore, the technique is technically more demanding than standard cataract surgery, and the transscleral suture pass carries inherent risks of iatrogenic trauma, such as to the ciliary body, or inadvertent posterior capsule rupture. Finally, achieving perfect IOL centration and avoiding tilt is highly operator-dependent, and suboptimal positioning could induce higher-order aberrations affecting visual quality. Therefore, larger, prospective studies with longer follow-up periods are warranted to further validate the long-term safety and efficacy of this technique.

Conclusion

This modified technique for intrascleral CTR fixation is a simple, reproducible, and cost-effective option for managing moderate-to-severe lens subluxation. By stabilizing the capsular bag with accessible materials, it enables predictable in-the-bag IOL implantation and provides outcomes comparable to more complex systems, thereby expanding treatment options, particularly in resource-limited settings.

Supplemental Material

sj-docx-1-oed-10.1177_25158414251407874 – Supplemental material for Intrascleral fixation of standard capsular tension ring: a modified-simple technique for managing moderate and severe subluxated lens extraction

Supplemental material, sj-docx-1-oed-10.1177_25158414251407874 for Intrascleral fixation of standard capsular tension ring: a modified-simple technique for managing moderate and severe subluxated lens extraction by Li Ning, Yingying Hong and Yinghong Ji in Therapeutic Advances in Ophthalmology

Supplemental Material

sj-docx-2-oed-10.1177_25158414251407874 – Supplemental material for Intrascleral fixation of standard capsular tension ring: a modified-simple technique for managing moderate and severe subluxated lens extraction

Supplemental material, sj-docx-2-oed-10.1177_25158414251407874 for Intrascleral fixation of standard capsular tension ring: a modified-simple technique for managing moderate and severe subluxated lens extraction by Li Ning, Yingying Hong and Yinghong Ji in Therapeutic Advances in Ophthalmology

Footnotes

Acknowledgements

The authors wish to express their gratitude to Dr. Yepei Qin for her valuable contributions to this work. Her efforts were instrumental in several key areas, including Data Curation, Investigation, and Writing – review & editing.

Declarations

ORCID iD

Yinghong Ji

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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