Comparative Two-Year Outcomes of Three Different Three-Piece Intraocular Lenses in Flanged Intrascleral Fixation

Abstract: Purpose: To compare 2-year positional stability, endothelial preservation, and best-corrected visual outcomes of three three-piece IOLs with differing haptic rigidity — Eyecryl (flexible), Sensar (intermediate PMMA), and MA60AC (rigid) — implanted via the Yamane technique. Methods: Retrospective analysis of 196 consecutive patients (196 eyes) with fully completed 24-month follow-up, using propensity-score weighting and linear mixed-effects models to assess longitudinal trajectories of ECD loss, IOL decentration, and ELP. Results: All groups achieved equivalent BCVA (TOST p=0.009). Operative time differed markedly (Eyecryl 12.9±3.4 vs. MA60AC 24.1±7.6 min; p<0.001). MA60AC had greater decentration (0.75±0.21 vs. 0.56±0.20 mm; p=0.001) and anterior ELP displacement (0.79±0.11 vs. 0.58±0.13 mm; p<0.001), with shallower ACD (3.42 vs. 3.61 mm; p=0.02), but no tilt difference (p=0.312). Unadjusted 24-month ECD loss was 4.92±1.52% (Eyecryl), 6.18±1.87% (Sensar), and 7.45±2.01% (MA60AC; all pairwise p<0.001). Independent ECD predictors included operative duration (β=0.042%/min), ELP (β=1.28%/mm), decentration (β=0.465%/mm), and Sensar type (β=0.534%; all p<0.05). The MA60AC coefficient lost significance after mediator adjustment (β=0.398%, p=0.136), indicating mediation through surgical factors. Conclusions: All three IOLs provided equivalent 2-year vision. Eyecryl offered superior stability and lower unadjusted ECD loss than MA60AC. The MA60AC-related endothelial attrition appears mediated by prolonged surgery and anterior optic position, not direct haptic toxicity. Translational Relevance: Optimize externalization speed, flange symmetry, and centration to reduce rigid‑haptic endothelial impact; flexible haptics suit low‑reserve corneas. Guides IOL choice and technique refinement. Keywords: Yamane technique, flanged intrascleral fixation, three-piece IOL, corneal endothelial cell loss, IOL decentration