Since the introduction of intraocular lenses in cataract surgery by Sir Harold Ridley this became standard of care in late 80ies. Whenever possible, in-the-bag implantation with overlapping continuous curvilinear capsulorhexis is preferable. But various IOL models and fixation sites and techniques are recommended for difficult situations.

Anterior chamber lenses were used for many years because of relatively easy implantation technique even in the total absence of capsular support. But the fixation in the anterior chamber angle may cause glaucoma and chronic irritation to iris. Furthermore long term endothelial cell loss with corneal decompensation is reported for angle fixated intraocular lenses as well as for iris claw lenses fixed to anterior surface, a technique introduced by Jan. Worst almost thirty years ago. Both require relatively large incisions up to 6.5 mm. For iris claw lenses Uveitis-Glaucoma-Hemorrhage Syndrome is reported and late dislocations may occur. Anyway if someone would use this type of lens we recommend the retropupillary reverse implantation technique [21]. This is much more convenient because it prevents contact to corneal endothelium intraoperatively i.e. during fluid-air-exchange during a pars plana vitrectomy and postoperatively due to eye rubbing, blinking etc. Iris fixated IOL tend to cause IOL wobbeling with optical side effects and unstable vision. Some surgeons prefer iris-sutured intraocular lenses. This could cause pupil ovalisation and iris chaffing with uveitis and/or pigment dispersion and secondary complications like chronic inflammation and secondary glaucoma. Anyway these techniques need sufficient iris stroma for fixation and cannot be used in aniridic patients.

We are convinced that the best place for fixation of intraocular lens in the absence of sufficient zonular/capsular support is the sclera. It is the strongest intraocular tissue, mainly avascular and does not tend to inflammation. Vitreoretinal surgeons know for decades that implants and explants for retinal procedures are well tolerated over a long period. In moderately damaged zonular apparatus we are using for many years capsular bag refixation techniques with modified capsular tension rings (s.c. Cionni ring) or Ahmed segments (both Morcher, Germany). These implants are positioned in the capsular bag and have an extra eyelet which is positioned on the anterior surface of the anterior capsule and fixed with a 10 × 0 or 9 × 0 Prolene suture transsclerally into the ciliary sulcus. This technique is difficult and needs an intact capsulorhexis. Furthermore capsular bag cleaning is diminished. This tends to cause early secondary cataract and capsular fibrosis with rhexis phimosis. For more severe luxated capsular bags or for fixation of intraocular lenses in the absence of sufficient support the haptic of the intraocular lens could be knotted to a 10 × 0 or 9 × 0 Prolene suture and fixed to the scleral wall. Many variations of transscleral suture fixation are reported and these techniques are used worldwide because small incision techniques can be used, intraocular lens is positioned more physiologically in the posterior chamber and standard lenses could be used. In case of dislocated intraocular lens this could be refixated by intraoperative haptic externalization for knot fixation to the haptic and transsclerally suturefixation without need for intraocular lens explantation. A fibrosed capsular bag esp. if with capsular tension ring in place can easily refixated with double armed 10 × 0 or 9 × 0 Prolene suture to the ciliary sulcus. The first needle is passed through the capsule catching the haptic and/or capsular tension ring and passed through the sclera while the second needle is just placed above the bag through the sclera. The so created suture loop will hold the bag after knotting to the sclera. Usually more than one sclerafixation is necessary to stabilize the whole bag. Recently Richard Hoffmann reported a technique for transcleral suturefixation without opening of conjunctiva [22]. Here the pockets for suture knots are prepared from the limbus intrascleral towards the sclera, a double armed suture is used and stitched 1.5 mm postlimbal through the scleral pockets and conjunctiva, needles are cut off and the sutures are catched with a hook from the limbus. Then the suture is knotted and the ends are buried into the scleral pocket.

However centration of suturefixated intraocular lenses is difficult and lens tilt is a common problem. This will result in internal astigmatism and inconvenient refractive outcome. Fixation into the ciliary sulcus without capsular and zonular support is difficult and malpositioning may result in chronic irritation to ciliary body and/or iris with secondary complications. Good long term stability is reported but late dislocations due to suture biodegradation may occur and require reinterventions [23–27]. There is a long learning curve for suturefixation techniques and outcome is very much depending on surgeons experience. Furthermore there could be a need for special intraocular lens, which may not be available everywhere and prompt, need extra costs and logistics, adapted biometry etc.

For these reasons we were searching for technique for intraocular lens fixation in the absence of sufficient capsular support which uses a standard foldable intraocular lens, sclerafixation, is independent from iris changes and the amount of zonular/capsular damage, sutureless, reduces the contact to uveal tissue and could be standardized.

In 2006 we performed the first intrascleral haptic fixation of a standard three piece intraocular lens and reported the surgical technique in 2007 [28].