Intraoperative Events During Posterior Chamber Phakic Intraocular Lens Implantation: A Systematic Review And Proposal For A Mechanism-Based Reporting Framework

To systematically characterise intraoperative events associated with posterior chamber phakic intraocular lens (pIOL) implantation and to propose a standardised classification framework to address inconsistencies in current reporting.

Systematic review of published clinical studies evaluating posterior chamber phakic intraocular lens implantation across multiple international surgical centres and device generations.

A systematic review of the literature was conducted using PubMed from database inception to 2025. Clinical studies evaluating pIOL implantation across all device generations were included. Intraoperative findings were extracted verbatim and synthesised, and mapped to a newly developed four-class, mechanism-based reporting framework distinguishing (1) technical or device-handling events, (2) manipulation-related tissue interaction events, (3) assessment and sizing-related events, and (4) true intraoperative complications involving structural tissue injury or pressure-related harm. Studies reporting no intraoperative events or omitting intraoperative findings were also quantified to assess the completeness of reporting.

Terminology describing intraoperative findings was highly inconsistent, with more than 30 distinct descriptive terms identified. Twenty-two studies (47%) explicitly reported at least one intraoperative event, while the remainder either reported no events or omitted intraoperative findings entirely. Reported events were uncommon and predominantly minor, most frequently involving lens handling, orientation, vault assessment, iris interaction, or transient endothelial contact. True intraoperative complications—such as crystalline lens injury, zonular damage, or capsular violation—were rare and largely confined to earlier-generation devices. Heterogeneous terminology and incomplete reporting substantially limited cross-study comparability.

Intraoperative complications during pIOL implantation are uncommon; however, current literature is characterised by inconsistent terminology and frequent omission of findings. The proposed four-class classification framework provides a structured approach to intraoperative event reporting, facilitating transparency, cross-study comparison, and improved interpretation of intraoperative safety data in future phakic IOL research.