In cases where placing an IOL in the bag/sulcus is not possible, how do you decide between leaving a patient aphakic for a scleral-fixated IOL (assuming this can't be done immediately) vs. placing an ACIOL?

In 2 situations, I would leave a patient aphakic even without an IOL:

• highly myopic patients where the actual IOL power is minimal +\- 3 D, in that case, glasses can correct residual refraction, supposing that the patient does not develop anisometropia
• monocular patients with up to 5 D residual ref...

In general, I try to avoid placing an ACIOL unless the patient is older and I think going through another surgery may be more risk than reward. Well-placed ACIOLs can do well for decades, but I still prefer scleral fixation when possible.

This is a clinical decision based on multiple factors. Including but not limited to the patient’s age, pre-op refractive state, co-morbidities, and surgical circumstances that led to this decision. Most ophthalmologists reflexively believe that the ACIOL creates the future ocular complications. But ...