to report the case of a patient with a damaged haptic of an acrylic intraocular lens ( iol ) after transscleral iol fixation . he had undergone phacoemulsification / aspiration and iol implantation 3 years previously and iol repositioning with transscleral fixation 2 years before the initial visit . his visual acuity was 0.3 in the left eye due to corneal edema caused by a foreign body , i.e. , the severed haptic tip of the single - piece acrylic iol , which was surgically removed . the surface of the tip of the haptic suggested that the monofilament suture thread had exerted continuous force across the haptic . foldable intraocular lenses ( iols ) have recently replaced polymethylmethacrylate iols for use in transscleral fixation surgery and standard cataract surgery because they can be implanted through a small incision . favorable outcomes with sutured acrylic iols have been reported [ 1 , 2 , 3 , 4 , 5 , 6 ] . however , various postoperative complications associated with suturing foldable iols have also been discussed , since they are not designed for transscleral suturing [ 1 , 6 , 7 , 8 , 9 , 10 , 11 ] . we report a case with a damaged haptic of a single - piece acrylic iol 2 years after transscleral fixation . a 40-year - old man was referred with sudden visual loss in his left eye ( le ) in october 2010 . informed consent was obtained , and the treatment protocol has been approved by the local committee of the national tokyo medical center . in 2007 , he underwent phacoemulsification and iol implantation for a cataract in the le . iol subluxation occurred in 2008 , and the patient underwent a repositioning surgery , with suturing of the iol transsclerally without iol exchange . detailed information of these two surgeries performed prior to the initial visit to our institute was unavailable ; the underlying pathogenesis of the cataract and iol subluxation was unknown . at the initial examination in our clinic , best - corrected visual acuity ( bcva ) was 0.3 with correction of 3.75/2.25  180 in the le . slit - lamp examination showed prominent corneal stromal edema from 2 to 7 o'clock ( fig . gonioscopy showed a foreign body at the bottom of the anterior chamber touching the corneal epithelium ( fig . the foreign body was thought to be the distant tip of a haptic of a single - piece acrylic iol . postoperatively , the corneal condition , presumably resulting from the foreign body , recovered gradually within 2 months and the edema resolved ; the endothelial cell count was 1,744 cells / mm , and the bcva was 1.0 with correction of 2.25/2.00  180 . during the postoperative comprehensive ophthalmologic examination , the iol was seen to be slightly tilted and mobile and one of the haptics was damaged ; otherwise , no abnormality was seen in the fundus or posterior chamber . an iol exchange was performed combined with 25-gauge pars plana 3-port vitrectomy in february 2011 . intraoperatively , the sutured side of the iol was observed with scleral indentation ; the haptic was sutured firmly at the appropriate position ( 10 o'clock ) in the ciliary sulcus . the opposite haptic was severed at the point where it was supposed to have been sutured . the suture was resected with vitreous scissors , and the iol was removed through a scleral tunnel . a new acrylic iol designed for a suturing procedure ( ya-65bb , hoya corp . ) was implanted using the standard transscleral fixation procedure ; ya-65bb has the largest diameter of 13 mm with pmma haptics which have bulbs on the haptic tips to affix the suture . the bcva improved to 1.2 with correction of cylinder of 2.00  135 , 1 month later . the tip of the haptic extracted previously was part of the explanted iol , which was identified as a single - piece acrylic lens ( acrysof sa60at , alcon laboratories ) . the damaged site of the haptic was directly opposite the point at which the other maintained haptic was sutured but slightly proximal to the optic ( fig . the detailed observation of each fragment revealed that the two parts fit together perfectly with no other parts of the iol missing . the surfaces of the severed portions were relatively smooth and flat with numerous tiny fissures ( fig . a thin monofilament suture thread was also seen adhering to the proximal aspect of the severed haptic ( fig . the distance between the site of the damage and the point of the suture on the other side was 10.5 mm . transscleral fixation is a desirable method to implant iols in eyes with inadequate capsular support . along with the trend toward small - incision surgery , foldable iols have become a favorable alternative to transscleral fixation [ 1 , 2 , 3 , 4 , 5 , 6 ] . transscleral fixation has also been performed during surgery to reposition dislocated iols , using two major methods : externalizing the haptics through a clear corneal incision and tying a looped suture intraocularly using the cow hitch - knot technique [ 7 , 8 , 10 , 13 , 14 ] . these procedures do not require an incision for an iol exchange , since the dislocated iol is suture - fixated again [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 13 , 14 ] , which possibly reduces the risk of postoperative astigmatism or loss of corneal endothelium [ 8 , 13 , 14 ] . possible complications associated with transscleral fixation of foldable iols have also been discussed previously , i.e. , iol decentration , tilt , rotation or luxation , slippage of the suture thread off the haptic , and damage to the haptic [ 1 , 6 , 7 , 8 , 9 , 10 , 11 ] . these complications are thought to result from the characteristic design and material of foldable iol haptics , e.g. , the absence of an eyelet or bulb to affix the suture , instability of the haptic - optic junction , and softness of the jelly - like material . the haptic of the single - piece acrylic iol implanted in the current case was very soft , which may be the reason it was damaged . the diameter of the iol is additionally crucial to minimize stress on the single - piece acrylic iol that is sutured . based on published data , the diameter of the posterior chamber at the level of the ciliary sulcus can be estimated to range from about 10 to 12 mm . in the current case , the largest diameter of the damaged iol was 13 mm , which seems sufficient to provide stability after suture fixation . if the distance between the two sutured parts was less than the diameter of the posterior chamber , the thin monofilament suture would induce continuous force across the haptic and gradually slice the jelly - like material of the haptic of a single - piece acrylic iol . this hypothesis is supported by the tiny fissures on the relatively smooth surfaces of the cross - sections with the adherent suture thread . while unpredictable complications can arise from inappropriate choices of a foldable iol , foldable iols are advantageous even in suture fixation . attention should be paid to the iol design and material even during primary cataract surgery , and the possible complications of suturing those iols should also be considered ; the complications may occur later , as there would be no chance to exchange the iol during repositioning surgery with transscleral fixation . in addition , surgeons performing an iol repositioning procedure should evaluate the design and material of the previously implanted iol , and plan to exchange the iols when needed . development of foldable iols suitable for both primary cataract surgery and transscleral fixation should solve this problem .