Investigation of factors influencing intraocular lens implantation strategy following capsular tension ring implantation

OBJECTIVE: The aim of this study was to evaluate the determinants of post-operative visual acuity and the factors influencing surgeons’ intraocular lens (IOL) implantation strategy in eyes undergoing capsular tension ring (CTR) implantation during cataract surgery.
METHODS: This retrospective observational cohort study evaluated the outcomes of phacoemulsification with CTR implantation performed between 2023 and 2025. Pre-operative variables included age, cataract stage, and pseudoexfoliation (PEX); intraoperative parameters comprised the extent of zonular dialysis and vitreous prolapse. Multivariable regression, with effect sizes reported as odds ratios or β coefficients and 95% confidence intervals (CIs), was used to identify factors associated with post-operative visual outcome and with IOL implantation strategy.
RESULTS: Of 89 eyes (of 89 patients), 23 received a three-piece sulcus IOL and 66 an in-the-bag foldable IOL. Best-corrected visual acuity (BCVA) improved from a median of 1.0 (interquartile range [IQR] 0.5–1.9) to 0.2 (IQR 0.1–0.4) logMAR (mean 0.37±0.49; p<0.001). Sulcus implantation was more frequent in eyes with greater zonular dialysis (median 90° vs. 0°; p=0.014), vitreous prolapse (p=0.017), and PEX (p=0.035). No significant difference in post-operative BCVA was detected between the two groups (median 0.2 in both; p=0.98). In the multivariable model, greater zonular dialysis (odds ratio [OR] 1.10/10°, 95% CI 1.01–1.20) and vitreous prolapse (OR 5.84, 95% CI 1.27–26.9) were independently associated with sulcus implantation. Post-operative BCVA was associated with pre-operative visual acuity rather than with IOL position; cataract stage was associated with the outcome in univariable analysis (p=0.035) but not after adjustment for pre-operative BCVA (β=−0.19, p=0.062).
CONCLUSION: In this CTR-treated cohort, favorable 12-month visual and lens-related outcomes were observed across a wide range of zonular compromise. Greater zonular dialysis and vitreous prolapse were independently associated with sulcus IOL implantation. No difference in 12-month BCVA was detected between the two strategies; given the sample size, this indicates the absence of a detected difference rather than equivalence of the two approaches. The findings should be considered hypothesis generating rather than confirmatory and warrant validation in larger prospective, multicenter studies incorporating objective assessments.