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In the event of an inadequate capsular bag support, an intraocular lens can be fixated by suturing one or both haptics to the iris. For suture fixation of intraocular lens to iris, a three-piece intraocular lens is selected [1]. The intraocular lens power selected is the same as that for sulcus fixation. In the setting of a partial capsular support, as the situation usually is when this method of intraocular lens fixation is selected, one of the haptics is centered over the remnant anterior capsule and the other haptic is fixated to the posterior aspect of the iris. For suturing, a 10–0 polypropylene, on a long curved needle, is preferred [1]. The prerequisites for selecting this technique are a normal iris architecture and thorough anterior vitrectomy to clear all vitreous in and around the pupil.

The lens capsule in human eyes has the maximum thickness in the anterior midperipheral region located just anterior to the site of insertion of the zonules. The capsule thickness increases with age, especially at the anterior pole, while it stabilizes in the midperipheral zone or slightly decreases after the seventh decade. From this point, the posterior capsule becomes progressively thinner and also diminishes with age, except for the thinnest, but stable posterior pole [1]. The posterior capsule acts as an anatomical barrier between the anterior and the posterior segment and limits the spread of infectious and inflammatory processes [2].

Intraocular lens (IOL) implantation in cases lacking sufficient capsular support is challenging to the anterior segment surgeon. If the anterior capsule is intact and with no tears at the capsulorhexis margin, then a sulcus fixation is preferred by most surgeons; however, square-edged one-piece hydrophobic lenses should be avoided. If there is no capsular support to ascertain stable fixation, then other alternatives are used, such as scleral fixation of a three-piece IOL, either by suturing or by placing the haptics in a scleral tunnel, iris fixation using sutures or iris claw lenses, and anterior chamber angle supported IOLs.

Perhaps the greatest fear of cataract surgeons is that of suddenly noticing a posterior capsular rent in what hitherto seemed to be a perfect “refractive” cataract surgical procedure. “Refractive,” because today all cataract surgeries aim to correct the patients’ underlying refractive errors, whether they are planned as clear lens extractions or procedures to restore functional vision for disabled patients with bilateral dense brunescent or mature cataracts. Since the first ultrasonic biometers became available in the early 1980s, we have progressively refined our “standard” techniques to enable ophthalmic surgeons to ever more accurately enhance refractive results from cataract surgery. We have evolved to have extremely high expectations, perhaps the highest of any medical or surgical procedure currently performed. We regularly hear our patients say that they see better after our surgery than they ever have before. Ultrahigh expectations contribute to the surgeon’s already high anxiety about increased risk for complications when a capsular rent appears, often bordering on panic, especially now that capsular tears are becoming much less common, approaching 1 % of cases or less.