Purpose To compare the outcome of primary anterior chamber vs secondary scleral-fixated intraocular lens (IOL) implantation in complicated cataract surgeries. Design Retrospective, comparative study. Methods A consecutive series of complicated cataract surgeries with primary anterior chamber (ACIOL) or secondary scleral-fixated IOL implantation from January 1, 2004 to December 31, 2009 was analyzed. Main outcome measures included the postoperative best-corrected visual acuity (BCVA) and postoperative complications. Results There were 89 eyes in the primary ACIOL group and 74 eyes in the secondary scleral-fixated IOL group. The mean follow-up duration was 64.1 ± 36.7 months. The mean postoperative logarithm of minimal angle of resolution (logMAR) BCVA at 1 year was 0.32 ± 0.54 and 0.34 ± 0.21 in the primary ACIOL group and the secondary scleral-fixated IOL group, respectively ( P  = .734). The mean latest logMAR BCVA was 0.68 ± 0.54 and 0.61 ± 0.47 in the primary ACIOL group and the secondary scleral-fixated IOL group, respectively ( P  = .336). The primary ACIOL group had more early postoperative complications ( P < .001). No difference in late postoperative complications was observed between the 2 groups ( P  = .100). Regression analysis showed that primary ACIOL and secondary scleral-fixated IOL implantation had similar latest postoperative logMAR BCVA ( P  = .927), while the presence of late complications was associated with a worse final visual outcome ( P  = .000). Conclusions This study shows that there are no long-term differences in the visual outcomes and complication profiles after primary ACIOL or secondary scleral-fixated IOL implantation in a complicated cataract operation when capsular support is inadequate.