In cases where placing an IOL in the bag/sulcus is not possible, how do you decide between leaving a patient aphakic for a scleral-fixated IOL (assuming this can't be done immediately) vs. placing an ACIOL?

In 2 situations, I would leave a patient aphakic even without an IOL:

• highly myopic patients where the actual IOL power is minimal +\- 3 D, in that case, glasses can correct residual refraction, supposing that the patient does not develop anisometropia
• monocular patients with up to 5 D residual refraction when aphakic, supposing that the patient does not mind wearing glasses

The only time I would do an ACIOL is for someone older than 85 or who has a low life expectancy. I believe that AClOLs are harmful to younger patients; most of them develop corneal decompensation later, which often requires a more complex DSEAK combined with IOL exchange. Otherwise, scleral fixation is your choice.

In general, I try to avoid placing an ACIOL unless the patient is older and I think going through another surgery may be more risk than reward. Well-placed ACIOLs can do well for decades, but I still prefer scleral fixation when possible.

This is a clinical decision based on multiple factors. Including but not limited to the patient’s age, pre-op refractive state, co-morbidities, and surgical circumstances that led to this decision. Most ophthalmologists reflexively believe that the ACIOL creates the future ocular complications. But it is surgical complications and surgical corrective actions that usually lead to the long-term complications of ACIOLs, not the ACIOL itself. A correctly sized and placed ACIOL is safe in most circumstances. I once treated a PXGl patient with an incorrectly sized ACIOL. Biometer readings measured the wrong WTW distance. She was undersized and developed a UGH syndrome. She had previously been to some of the top eye centers in the country. She had...