Sutureless capsular bag–intraocular lens complex scleral fixation using iris retractors in eyes with crystalline lens subluxation: long-term outcome

Abstract

The aim of the study was to evaluate the visual outcomes, safety and efficacy of the surgical technique used for repositioning and scleral fixation of the capsular bag – intraocular lens (IOL) complex in the surgical treatment of subluxated lenses. The study was prospective and performed between 2021 and 2025. Study included patients with different degrees of lens subluxation in cases of zonular dialysis. All patients underwent surgery using a capsular tension ring (CTR) and iris retractors, which were externalized through the sclera and cauterized to provide permanent scleral fixation of the capsular bag. Clinical and refractive outcomes were analyzed to evaluate intraocular lens stability, including tilt and decentration measurements at one year postoperatively. Safety analysis consisted of complication assessment. This study included 36 eyes from 32 patients. Mean follow-up was 396.72 ± 98.26 SD days. Mean surgical time was 40.08 ± 12.9 min. Postoperative BCVA was 0.09 ± 0.18 logMAR at one year follow-up. Postoperative total refractive error (RE) was + 0.68 ± 1.21D. Endothelial cell loss was 4.96% (123.94 cells/mm²) at one year follow-up. Mean vertical and horizontal tilt were 3.84° ± 1.78° and 4.23° ± 2.98° (p = 0.61). Mean vertical and horizontal decentration were 0.29 ± 0.14 and 0.30 ± 0.18 mm, respectively (p = 0.83). No cases of displacement capsular bag - IOL complex were reported. Long-term follow-up data suggest that simultaneously using CTR and iris retractors for permanent scleral fixation of the capsular bag – IOL complex demonstrates good visual and refractive outcomes in lens subluxation. This technique provides safe and effective long-term stabilization.

Trial registration: ClinicalTrials.gov identifier, NCT07257172. Retrospectively registered, registration date 20.11.2025.

Introduction

One of the current challenges in cataract surgery remains the removal of cataracts complicated by zonular weakness and lens subluxation. The range of diseases associated with lens subluxation of varying severity is constantly growing. The main cause of lens dislocation is damage to the zonular fibers due to ocular trauma^1,2 or congenital diseases such as Marfan syndrome^3,4.

In recent years, the widespread use of phacoemulsification, together with the development of various modifications for capsule stabilization such as iris hooks⁵ and capsular retractors, has improved the management of lens subluxation. Additionally, extensive use of flexible intraocular lens (IOL) models and implantation of capsular tension ring (CTR) have significantly expanded possibilities for surgical rehabilitation in these patients. Improvements in microsurgical techniques and early diagnosis of the lens capsule pathology allow such lenses to be removed with reduced risk of intraoperative and postoperative complications. Microinvasive techniques are currently preferred in ophthalmic surgery.

There are many techniques for scleral fixation of IOL. Whenever possible, efforts should be made to preserve the lens capsule, as it provides the most physiological and stable placement of the IOL. Introduction of sutureless, two-point fixation of IOL, proposed a few years ago by Japanese surgeon Shin Yamane, has enabled development of new sutureless fixation techniques and has also allowed for reduction in surgical time⁶.

The surgical technique employing a CTR and iris retractors, with the retractor ends externalized through the sclera and cauterized to achieve permanent scleral fixation of the capsular bag, allows preservation of the capsular bag⁷. It can be used in both congenital and acquired lens subluxation, enabling capsule preservation even in cases of severe subluxation.

The main objective of our study was to evaluate the effectiveness and safety of this technique. We also analyzed position and stability of the capsular bag-IOL complex.

Methods

This study was prospective and was conducted at the Military Institute of Medicine - National Research Institute in Warsaw between 2021 and 2025. The study was conducted in accordance with the tenets of the Declaration of Helsinki and was approved by the Bioethics Committee of the Military Institute of Medicine- National Research Institute in Warsaw (NR 12/ WIM/2021). All patients provided informed consent.

The study included only adult men and women with zonular defect greater than or equal to 90 degrees. This study included patients with zonular dialysis of traumatic, congenital, and Pseudoexfoliation syndrome (PEX) etiology. The indication for lens extraction was lens subluxation with vision deterioration due to cataract. All surgeries were performed by the same surgeon (M.Rekas). Technique for capsular bag – IOL complex stability was the same in all cases, but, if necessary, iris coloboma closure, iris dialysis suturing or pupiloplasty were performed simultaneously.

Exclusion criteria for this study included corneal diseases (corneal dystrophy, history of corneal transplantation), additional severe ocular pathology unrelated to cataract subluxation or trauma, and other retinal diseases (retinal detachment, retinal vein occlusion).

All patients received ophthalmic examinations before and after the surgery at different time points (day 1, 7; months 1, 3, 6, 12). Full ophthalmic examination included uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), tonometry, corneal endothelial cell density, slit-lamp anterior and posterior segment examination (OCT and B-scan ultrasonography, when the fundus was not visible) and biometric values. Preoperative biometry was performed using the Zeiss IOL master 700 (Carl Zeiss Meditec, Jena, Germany), and the theoretical Sanders-Retzlaff-Kraff (SRK/T) formula was used to calculate lens power. Our choice of target refraction (TR) was based on the aim to achieve the best possible uncorrected visual acuity for distance while minimizing postoperative refractive error (RE). In eyes with lens subluxation undergoing scleral fixation of the capsular bag – IOL complex, precise refractive predictability may be limited due to potential variations in effective lens position. TR was individualized based on preoperative refractive status. TR of − 2.5 D was selected to preserve near vision for myopic patients. For all other patients a near-emmetropic TR of − 0.25D was chosen to optimize uncorrected distance visual acuity while minimizing the risk of postoperative hyperopia. In cases of astigmatism greater than 2 diopters, a toric IOLs was implanted.

Lens position was assessed using AS-OCT (Anterion, Heidelberg Engineering, Germany) in all cases.

UCVA and BCVA were measured using Snellen vision chart, which was converted to logMAR values. Additionally, changes in intraocular pressure (IOP), RE, and endothelial cell density (ECD) were evaluated at 1 year follow-up. Postoperative total RE was calculated as the difference between expected and actual refractive error after the surgery. Intraoperative and postoperative complications, such as anterior chamber bleeding or vitreous cavity bleeding, corneal edema, macular edema, retinal detachment, lens-capsule complex dislocation, and retractor tip extrusion, were also evaluated.

All statistical calculations were carried out using the statistical package StatSoft. Inc. STATISTICA (data analysis software system) version 13.0. Quantitative variables were summarized using mean, standard deviation, median, minimum and maximum values (range), and 95% confidence intervals (95% CI), while qualitative variables were presented as counts and percentages. Statistical significance was set at p ≤ 0.05. Correlations between variables were evaluated using Pearson’s or Spearman’s correlation coefficients, depending on data distribution.

This surgical technique has been previously described and published by us in 2022⁷. The procedure was performed under retrobulbar anesthesia using a 2% solution of xylocaine and 0.5% solution of bupivacaine. Main incision was 2.2 mm temporal clear corneal incision. The next step was to perform capsulorhexis using forceps, avoiding excessive pressure on the zonular fibers. Sometimes, two surgical instruments were used at this stage to stabilize the nucleus. It was usually necessary to perform an anterior vitrectomy for cases with vitreous prolapse (Fig. 1A). Iris retractors (Iris Care, Madhu Instruments Pvt. Ltd.) were then inserted through additional lateral ports. Iris retractors used in this technique are manufactured in a single standard size. Flexible iris retractors, made of bright blue polypropylene, were applied. Each retractor consists of a flexible polypropylene hook with an adjustable silicone stopper. Devices were placed beneath the anterior capsular margin in the area of zonular damage to engage the edges of the capsulorhexis. After stabilizing the capsular bag, phacoemulsification was performed (Fig. 1B). CTR was implanted into the capsular bag (Fig. 1C). Next, a foldable monofocal IOL was inserted into the capsular bag (Fig. 1D). In the case of toric IOL, the lens is positioned along the correct implantation axis. The intended toric IOL axis was marked preoperatively on the cornea using a corneal marker ring. After removing the silicone plugs, the retractors were detached from the edge of the capsulotomy and placed in the anterior chamber of the eye. A 25 G needle was inserted into the anterior chamber 2 mm behind the limbus, through the sclera at the site of zonular damage. The needle was advanced forward to the edge of the capsule. The tip of the retractor was inserted into the lumen of the needle using forceps and then brought out (Fig. 1E). This maneuver was repeated with another retractors (the number of retractors depends on the degree of damage) (Fig. 1F). After removing the retractor, the capsular bag - IOL complex was centered, so that the lens is in the visual axis. Tips of retractors were trimmed and cauterized (Fig. 1G). Melted tips of retractors were then withdrawn and fixed subconjunctivally. In cases of iris defects (iris coloboma, iris dialysis), they were closed using sutures (Fig. 1H). Next openings in the cornea were sealed and finally an antibiotic was injected into the anterior chamber. Standard postoperative treatment (antibiotics and topical anti-inflammatory drugs) was administered to all patients after the surgery.

Fig. 1.

Phacoemulsification of subluxated lens, CTR implantation and sutureless fixation to the sclera of the capsular bag - IOL complex with permanent use of iris retractors with simultaneous reconstruction of the iris defect. Anterior vitrectomy (A). Phacoemulsification (B). CTR implantation (C). IOL implantation (D). Insertion of the end of the retractor into the lumen of the needle (E). Externalization of the 3rd retractor using a 25-gauge needle (F). Cauterization of the trimmed iris retractors (G). Suturing of the iridodialysis (H).

The surgery was published online on Video Journal of Cataract, Refractive & Glaucoma Surgery, Vol. 35, Issue 1[History and Evolution of Zonular Surgery (Part 2)]⁸.

Results

The study included 36 eyes of 32 patients with greater than or equal to 90 degrees of the cataractous lens subluxation, comprising females and males. Mean age of patients was 50.6 ± 17.67 SD (range 18–83 years). Mean follow-up was 396.72 ± 98.26 SD. The most common cause of lens subluxation was ocular trauma, which was found in 66.7% (24 cases). Demographic characteristics, ocular history, and other causes of lens subluxation are presented with details in Table 1.

Table 1.

Demography characteristics and clinical history.

Parameter	Number, %
Total patients Female Male	32 8 (25%) 24 (75%)
Total eyes OD OS	36 17 (47.2%) 19 (52.8%)
Age Mean ± SD (years old) Range (years)	50.17±17.67 18.0–83.0
Follow-up time Mean ± SD (days)	396.72 ± 98.26
AL (mm, mean ± SD): Range (mm) < 21 mm 21‑25 mm > 25 mm	23.72 ± 1.07 21,21–26,70 0 (0%) 35 (97.22%) 1 (2.78%)
Mean IOL power calculation (D) Range (D)	22.27± 3.65 16–29,5
Type of IOL Alcon SA60AT Alcon SA60WF Alcon MA60AC HOYA Bausch&Lomb enVista MX60T	18 (50%) 9 (25%) 1 (2.78%) 1 (2.78%) 7 (19.44%)
Surgical time (min, mean ± SD) (Range, min): With reconstruction iris defect Without reconstruction iris defect	40.08 ± 12.9 (18–85) 49.2 ± 22.24 (30–85) 38.38 ± 11.5 (18–60)
Cause of subluxation Marfan syndrome Ocular trauma: Female/Male Pseudoexfoliation	7 (19.4%) 24 (66.7%):5 (13.9%)/19 (52.78%) 5 (13.9%)
Duration of subluxation Mean ± SD (months) (Range, months)	198.85 ± 208.67 (1–600)
Ocular history Myopia Iris dialysis Coloboma iris Traumatic iris defects Vitreous prolapse Glaucoma	9(25%) 2 (5.56%) 1 (2.78%) 4 (11.11%) 4 (11.11%) 11 (30.56%)

no. – number; OD – right eye; OS – left eye; SD – standard deviation; AL – axial length.

Mean surgical time was 40.08 ± 12.9 SD (range 18–85 min.). Simultaneous reconstruction of the iris defect was performed for 5 patients (13.9%), resulting in a longer procedure time (Table 1). During the surgery, 1 to 4 retractors were used for fixation of the capsular bag-IOL complex, depending on the degree of the lens subluxation (Table 2). Mean of the lens subluxation degree was 194.03 ± 80.08 SD (range 90–320). There were no intraoperative complications. Pre- and postoperative photographs of the patients are shown in Figs. 2 and 3.

Table 2.

Number of iris retractors required depending on the extent degree of lens subluxation.

Iris retractor used for fixation no.	Cases no.	Zonular defect Degree, mean ± SD (Range)
1	5	94 ± 5.48 (90–100)
2	16	136.56 ± 20.63 (110–180)
3	6	251.67 ± 39.62 (200–315)
4	9	298.89 ± 14.84 (270–320)

no. – number; SD – standard deviation.

Fig. 2.

Case report 1. Stil lamp photography of a 36-year-old man with Marfan syndrome with lens subluxation (A) and 6 months after surgery (B).

Fig. 3.

Case report 2. Stil lamp photography of a 64-year-old woman with post-traumatic cataract, vitreous prolapse (A) and 12 month after surgery (B).

Significant improvement was observed in UCVA, BCVA and refractive parameters in all patients after the surgery (Fig. 3). Mean preoperative BCVA was 0.60 ± 0.79 logMAR. The postoperative BCVA was 0.09 ± 0.18 logMAR at one year observation. Two patients achieved a slight improvement in visual acuity due to comorbidities (Fig. 4). Average postoperative total RE was + 0.68 ± 1.21 D. Mean RE for target refraction − 0.25D was + 0.99 ± 1.04 D and mean RE for target refraction − 2.5D was − 0.22 ± 1.22 D.

Fig. 4.

BCVA, UCVA, IOP at follow-up visits.

Mean preoperative endothelial cell count was 2493.08 ± 489.31cells/mm² and mean endothelial cell count was 2369.44 ± 622.74 cells/mm² at one year postoperative (p = 0.27). Mean cell loss was 4,96% (123.94 cells/mm²). Slight transient corneal edema was observed in 6 eyes (16,67%), which was resolved 1–2 weeks after the surgery, following the application of topical drops. No statistically significant correlations were found between duration of the surgery and the presence of edema (r = 0.29, p = 0.11) or between the number of retractors used and the presence of edema (r = 0.34, p = 0.07).

Mean preoperative IOP was 17.61 ± 3.94 mmHg (range 10–27). Postoperative IOP was 16.36 ± 3.32 mmHg (range 10–25) mmHg at one year observation (Fig. 3). Early ocular hypertension was observed during the first few days after the surgery in 3 eyes (8.33%). Intraocular hypotension was not observed in any case.

Mean vertical tilt was 3.84 ± 1.78° and mean horizontal tilt was 4.23 ± 2.98° at one year observation. No statistically significant difference (p = 0.61). Mean vertical decentration was 0.29 ± 0.14 mm and mean horizontal decentration was 0.306 ± 0.181 mm at one year observation. No statistically significant differences (p = 0.83).

Bleeding into the anterior chamber and vitreous hemorrhage occurred in one eye (2.78%). Slippage of the retractor in 1 patient (2.78%) was noted eight months after the surgery. Posterior capsule opacification (PCO) was observed in 1 eye (2.78%) at one year postoperatively. No cases of endophthalmitis, retinal detachment, cystoid macular edema (CME), extrusion of the retractor tip or displacement of capsular bag - IOL complex were reported.

Discussion

Lens subluxation remains a significant clinical challenge. The literature suggests that the main cause of lens subluxation is damage to the zonular fibers due to ocular trauma^1,2 or congenital diseases such as Marfan syndrome^3,4. This finding was confirmed in our study, in which ocular trauma accounted for 66.7% of cases and Marfan syndrome - for 19.4% cases. Pseudoexfoliation syndrome was present in 5 (13.9%) patients in our study. In eyes with PEX, surgery may be complicated due to the presence of small pupils and zonule laxity⁹.

A variety of capsular support devices can facilitate phacoemulsification and capsular bag fixation in subluxated cataracts¹⁰. CTR provides a means of stabilizing and reinforcing such zonules, ensuring safer cataract extraction, and well-centered implanted IOLs in long term¹¹. When zonular dialysis is less than 90° − 120°, implantation of a standard CTR is usually sufficient to provide adequate capsular support. CTR was used in all patients to achieve uniform capsular bag tension and equal force distribution in this study. Iris retractors were used up until now during phacoemulsification to perform surgery in eyes with small pupils or lens subluxation safely. By using iris hooks, the lens can be stabilized, helping to prevent an additional loss of zonules and permitting retention of the capsule to support IOL^12,13. Retractors were used not only as intraoperative stabilization devices but also ensured long-term stabilization of the capsular bag – IOL complex in our study. We presented postoperative results of the surgical technique which combines CTR implantation and scleral fixation using iris retractors to reposition and stabilize the capsular bag – IOL complex.

Mean duration of the surgery in our study was comparable to other surgical techniques and accounted for 40.08 ± 12.9 min. Zong et al.l. reported an average operation time was 49 ± 15.5 min for phacoemulsification using modified capsular tension rings (MCTR)¹⁴.

Endothelial cell loss observed in this study was 4,96% and was comparable to previously published data for standard phacoemulsification. Reported endothelial cell loss after uncomplicated cataract surgery generally ranges between 4% and 15% in the early postoperative period, depending on the surgical technique and case complexity^15,16. The literature states that after 12 months, an average total loss of endothelial cells was approximately 9%^17,18. Nishimura et al. reported the average loss of corneal endothelial cells was 14.5% when iris retractors were used¹⁹. Similar results were obtained by Zong et al. in their study, which found that corneal endothelial cell loss averaged 15.1 ± 8.7%, which is considered an important parameter of safety¹⁴. The extent of endothelial cell loss observed in our group is within the expected range, suggesting an acceptable level of safety and confirming that the procedure does not cause excessive endothelial trauma.

Mean IOL tilt and decentration observed in our study were comparable to values reported after standard phacoemulsification cataract surgery. Previous studies, using anterior segment optical coherence tomography, have reported mean tilt values of approximately 4.5–5.5° and decentration of 0.15–0.30 mm, following uncomplicated in-the-bag IOL implantation^20–22. Given that even minimal tilt (< 5°) or decentration (< 0.4 mm) may adversely affect optical performance, particularly in aspheric and premium IOLs, values obtained here confirm that this technique ensures clinically acceptable and optically safe IOL positioning, comparable to conventional cataract surgery.

Postoperative complications are similar to those described in the literature. Postoperative corneal edema is a recognized complication of phacoemulsification. Determined risk factors include corneal endothelial dystrophies, PEX, glaucoma, trauma, and others²³. Corneal edema occurred in 6 eyes (16.7%) in the present study, all of which were associated with a history of ocular trauma. This finding suggests that previous ocular trauma may play a significant role in the development of post-operative corneal edema. No statistically significant correlation was found between the frequency of corneal edema and duration of the surgery or the number of retractors used, suggesting that intraoperative factors related to the complexity of the procedure were not the main factors contributing to this outcome in our cases. Importantly, in all cases, the corneal edema was transient and resolved within 1–2 weeks, following topical treatment, without causing any long-term visual deterioration or clinically significant complications. These findings are consistent with previous reports, in which post-operative corneal edema is described as a condition, that is usually resolved spontaneously, particularly in the absence of severe endothelial dysfunction.

Transient elevation of IOP was observed in 3 cases and was successfully controlled with topical therapy. IOP returned to normal levels within 3–4 weeks, allowing discontinuation of treatment. These findings suggest that postoperative IOP elevation was temporary and did not result in long-term complications. Importantly, the clinical outcome and duration of the elevated intraocular pressure were consistent with the typically observed changes after eye surgery. Glaucoma was present in 11 of 36 eyes preoperatively in this study. Similar results were reported by Li et al., in whose study secondary glaucoma was present in 7 of 16 patients²⁴. Secondary glaucoma was primarily associated with ocular trauma, which was identified as the main underlying cause. Traumatic damage to the anterior vitreous membrane may result in vitreous entrapment in the anterior chamber and displacement of the lens-iris septum towards the anterior chamber as a result of the lens displacement. The resulting closure of the drainage angle and retraction of the angle may cause secondary glaucoma. In some patients, elevated intraocular pressure may occur prior to the surgery. Surgical intervention is necessary to address these complications. In our study, a reduction in the number of antiglaucoma medications was achieved in 5 eyes (13.9%), and complete discontinuation of topical therapy was possible in 1 eye (2.78%) postoperatively. These findings suggest that surgical stabilization the capsular bag – IOL complex may contribute to improved IOP control, potentially by restoring more favorable anterior segment anatomy.

In one case in this study, bleeding into the anterior chamber and vitreous hemorrhage, was observed after surgery in a patient with a history of trauma. Similar findings were described by Li et al. in the management of traumatic lens subluxation²⁴. This may indicate that prior ocular trauma plays a significant role in the pathogenesis of this complication. It is well known that injuries to the ocular trauma are accompanied by structural abnormalities, such as instability of the zonular fibers, a tear in the anterior vitreous membrane, and fragility of the retinal and ciliary body capillaries, which may contribute to intraoperative or postoperative haemorrhage. Furthermore, previous trauma may be associated with subtle changes in the body vitreous and retina, increasing predisposition to bleeding even in the absence of visible retinopathy. Importantly, in our case, the bleeding into the anterior chamber and vitreous hemorrhage, was resolving spontaneously and did not require any surgical procedures. This is consistent with reports, suggesting that mild postoperative vitreous hemorrhages in post-traumatic eyes are usually temporary. These results confirm the theory that such complications are usually related to previous ocular conditions, such as trauma, rather than to the surgical technique employed.

Late complications include posterior capsule opacification (PCO), which is a common postoperative complication after cataract surgery. Previous studies have reported an incidence ranging from 5 to 50%, depending on the follow-up duration and IOL characteristics²⁵. Chen et al. observed PCO in 22 eyes (21.36%) at 6 months, following MCTR-assisted surgery, in patients with Marfan syndrome with lens subluxation²⁶. In comparison, only one case (2.78%) of PCO was observed in our study after one year postoperatively, and it was successfully managed with Nd: YAG laser capsulotomy. This suggests a relatively low rate of this late postoperative complication. Simultaneous use of iris retractors and CTR improves capsular tension and distributes forces equally and may reduce the migration and proliferation of lens epithelial cells, thereby minimizing the risk of PCO. However, further studies involving a larger group of patients and a long-term follow-up observation are needed to confirm this finding.

Only one patient (2.78%) experienced retractor slippage, noticed eight months after surgery, but this did not lead to subluxation of the capsular bag – IOL complex. These results suggest that even in the absence of support, the whole complex may remain stable, probably due to adequate fibrosis and good stabilization of the capsular bag. Good stability of the complex was observed in all eyes during the follow-up, which confirms the efficacy of this technique in achieving long-term centration. This can be attributed to the even force distribution and effective intraoperative centration resulting from the use of several fixation points. Other authors also reported good results in terms of complex stability with other surgical techniques. Goldfeather et al. reports that the AssiAnchor capsule device achieved centration of the capsular bag and, consequently of the IOL, with no significant postoperative complications during the 12–24 months of follow‑up period²⁷. Ton et al., also used the AssiAnchor capsule device for the fixation of six cases of subluxated IOL and reported good centration and stabilization²⁸. However, Cionni et al. report that in 9 eyes (10%), the Prolene 10 − 0 suture broke one year after surgery, with 6 of them (6.7%) experiencing late symptomatic IOL displacement. They recommend 9 − 0 Prolene or 8 − 0 ultrathin polymer-treated (Gore-Tex) sutures for all MCTR patients²⁹. Findings reported in our study support the long-term stability and safety of sutureless capsular stabilization technique with iris retractors, as no displacement of the capsular bag – IOL complex was observed in any case during the follow-up period.

Importantly, no cases of endophthalmitis, retinal detachment, CME, or retractor tip extrusion were recorded in our study.

Our study’s advantages included the relatively large number of patients, one-year follow-up period, and the fact that all procedures were performed by a single surgeon. Furthermore, this approach does not impose additional financial burden on patients and may be readily implemented in routine clinical practice. This study has also limitations. The trial was registered retrospectively, which may raise concerns regarding study design transparency and outcome reporting. However, all patients were enrolled consecutively, and the data were collected and analyzed according to predefined clinical protocols, which reduces the risk of selection and reporting bias. Further studies with larger populations and longer follow-up are needed to confirm the long-term safety and effectiveness of this technique.

Conclusion

This surgical technique, which combines CTR implantation and scleral fixation, using iris retractors to reposition and stabilize the capsular bag – IOL complex, results in favorable visual and refractive outcomes in lens subluxation. This sutureless technique can be adapted to any degree of crystalline lens subluxation by adjusting the number of retractors according to the extent of zonular defect and may represent a valuable option in clinical practice. Importantly, the technique provides safe, effective, and durable long-term stabilization of the capsular bag–IOL complex, supporting its use as a valuable option in the surgical management of zonular weakness.

Author contributions

Prof. Marek Rekas performed the surgical procedures. Dr. Natalia Blagun collected the clinical data and participated in patient follow-up. Drs. Karolina Krix-Jachym and Natalia Blagun interpreted the results. Dr. Natalia Blagun drafted the manuscript. All authors critically revised the manuscript and approved the final version.

Funding

The Rapid Service Fee was funded by Military Institute of Medicine - National Research Institute.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable reuest.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The study was conducted in accordance with the tenets of the Declaration of Helsinki and has been approved by the Bioethics Committee of the Military Institute of Medicine. Ethics committee reference number is NR 12/WIM/2021. Informed consent to participate in the study was obtained from all subjects. All methods were carried out in accordance with relevant guidelines and regulations.

Medical writing, editorial, and other assistance

Medical writing for this article was done by authors - Natalia Błagun, Karolina Krix-Jachym and Marek Rekas.