When surgical disasters strike, the masters of IIIC Symposium show how to save the day.
Day 2 of the 37th annual meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2025) in Ahmedabad, India, opened with a session that truly lived up to its title: IIIC Lectures–The Perfect Save!
The International Intraocular Implant Club (IIIC) is a society unlike any other. Founded in 1966 by Sir Harold Ridley, the inventor of the intraocular lens (IOL), it unites some of the world’s most respected cataract and anterior segment surgeons. An IIIC symposium is held at every ASCRS and ESCRS annual meeting, and it has now become a regular highlight at APACRS gatherings.
Chaired by Prof. Dr. Michael Knorz (Germany), Prof. Ronald Yeoh (Singapore) and Dr. Abhay Vasavada (India), the symposium delivered on its promise: extraordinary cases where complications threatened disaster, and ingenious interventions transformed them into lasting success.
READ MORE: APACRS 2025 Tackles Tough Cases in Cataract and Refractive Surgery
Tackling trauma with femtosecond precision
Dr. Takashi Hida (Brazil) opened the session with a case that embodied unpredictability: an 8-year-old boy with a traumatic cataract complicated by fibrotic membranes across both anterior and posterior capsules.
“Traumatic cataract is unpredictable,” he reminded the audience. “We must be prepared with multiple IOLs—3-piece lenses, scleral-fixated IOLs, CTRs, hooks and always the possibility of vitrectomy.”
Dr. Hida showcased how a femtosecond laser-assisted cataract surgery (FLACS), adapted from his FLAIR technique (femtolaser-assisted IOL removal), can deliver precision even in fibrotic capsules. Using FLACS to fashion a perfectly circular capsulotomy, he was able to achieve stability for a 3-piece IOL in a case many would have abandoned.
His takeaway: preparation, flexibility and respect for the learning curve. “Above all, recognize that realism is the key to safe outcomes,” he concluded.
Marfan’s syndrome and the “anchor save”
From Brazil, the spotlight moved to the Netherlands with Dr. Ruth Lapid-Gortzak. Her case: a 62-year-old man with Marfan syndrome and zonular weakness.
Operating in an eye where the capsule felt “like chewing gum,” she turned to a novel polymethyl methacrylate (PMMA) anchor device to stabilize the bag. But even here, things got tricky: the flange she had crafted broke.
Her solution was elegantly simple: fold the suture over, cauterize and create a sturdier bulb. With persistence, she secured the anchor, stabilized the bag and implanted a 3-piece lens. The next day, her patient’s vision was 20/20 minus one letter.
Why not use a ring segment instead? Dr. Lapid-Gortzak explained: “The ring is often more difficult to bring into the bag, especially with a small rhexis. I find the anchor easier to do.”
Posterior polar cataracts
Dr. Dandapani Ramamurthy (India) turned the spotlight to posterior polar cataracts (PPC)—notorious for posterior capsule rupture. His advice is to do a routine swept-source anterior segment OCT (AS-OCT) before every PPC case.
“AS-OCT has become a norm for us,” he explained, presenting his series of 70 eyes. Surprisingly, 75% had intact capsules, allowing him to treat them like routine phaco cases.
But when the capsule was deficient, he demonstrated stepwise hydrodelineation and controlled nucleus removal. In one difficult case, even with a small posterior capsular defect, he successfully implanted a multifocal IOL after careful viscodissection and nucleus management.
“Know your capsule before you cut,” he ended his presentation. With AS-OCT, the perfect save often begins before the first incision.
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When IOLs go wrong
Prof. Thomas Kohnen (Germany) addressed a different nightmare: the damaged or malpositioned IOL. Whether from YAG capsulotomy, trauma or faulty folding, such cases demand precise exchange.
“Do not leave damaged IOLs in the eye,” he warned. “Patients will end up at another doctor who finds the problem—and the optics will cause aberrations.”
He showcased step-by-step strategies: from forceps removal to cutting thick, high-diopter lenses into parts to ease explantation through small incisions. His conclusion was pragmatic: always have a second lens ready and never compromise on optical quality.
The vitreous as an uninvited guest
Prof. Sri Ganesh (India) reminded the audience that even the most routine case can turn. What started as a straightforward cataract surgery turned into a struggle after a zonular dialysis (ZD) occurred during lens implantation.
Trying capsular tension rings (CTRs), capsular hooks and CTS devices, he found nothing was working. The bag tilted, the IOL decentered. Only when he finally introduced triamcinolone and performed a thorough vitrectomy did the puzzle fall into place.
“The vitreous is like an uninvited guest,” he reflected. “You may think you’re done, but if you don’t deal with it properly, it disturbs the peace.” So don’t patch over complications and address them decisively.
Bag rescue with capsular hooks
Prof. Chee Soon Phaik (Singapore) presented the case of a 52-year-old man with lens subluxation and vitreous prolapse. Faced with a lens at risk of dropping, she meticulously combined pars plana vitrectomy, capsular hooks and a CTR to stabilize the bag.
Every step was choreographed: “Capsule hooks, not iris hooks, are critical here, because they support the equator of the lens bag,” she emphasized. With viscodissection and careful phaco, she managed to implant the patient’s choice of an EDOF lens. The final sutured fixation produced a centered, stable IOL—and a delighted patient with 20/20 vision.
READ MORE: From Nightmare to Dream Vision
The double save: trauma and mydriasis
Closing the session, Dr. Yeo Tun Kuan (Singapore) presented a case of trauma with subluxation and traumatic mydriasis.
His strategy began with dispersive viscoelastics and capsular retractors to stabilize the lens. After phaco and CTR placement, he turned to address the glaring pupil defect.
Using suture-snare techniques with Gore Medical’s (Delaware, United States) Gore-Tex, he deftly reconstructed the iris. The final result? A stable lens, a round pupil and a grateful patient who returned to driving.
“I only learned from the best,” he said modestly, acknowledging mentors like Prof. Dr. Amar Agarwal.
READ MORE: APACRS 2025 Spotlights Innovations in Cataract and Refractive Surgery
The spirit of the IIIC
The IIIC Lectures at APACRS 2025 were more than a parade of surgical challenges. They were a window into the mindset of the world’s finest cataract surgeons. As each speaker demonstrated, what defines mastery is not the absence of complications, but the ability to adapt, innovate and finish with the patient’s vision preserved.
The Perfect Save may have been this year’s theme, but the deeper lesson was timeless: excellence in ophthalmology lies in preparation, adaptability and humility. That is why the IIIC remains a fixture at ASCRS, ESCRS and now APACRS—because no matter the stage or the theme, it is always about pushing the boundaries of what’s possible for patients.
Editor’s Note: The 37th annual meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2025) is being held from 21-23 August in Ahmedabad, India. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.