How to manage a Posterior Capsule Rupture (PCR) during Phacoemulsification?

Management of Posterior Capsule Rupture During Phacoemulsification

When posterior capsule rupture (PCR) occurs during phacoemulsification, immediately stop all surgical maneuvers, maintain anterior chamber depth, perform anterior vitrectomy if vitreous is present, and carefully complete the procedure with appropriate IOL placement—either in the capsular bag if sufficient support remains, in the sulcus, or as a secondary procedure.

Immediate Intraoperative Recognition and Response

Stop and Assess

• Immediately cease all phacoemulsification and irrigation/aspiration maneuvers when PCR is suspected to prevent vitreous prolapse and further extension of the tear 1, 2
• Recognize that PCR most commonly occurs during cortical removal (35.2% of cases), followed by segment removal (25.4%) 2
• Maintain anterior chamber depth with viscoelastic to prevent vitreous prolapse into the anterior chamber 3

Vitreous Management

• Perform anterior vitrectomy if any vitreous has prolapsed into the anterior chamber—this is critical to prevent postoperative complications including cystoid macular edema (CME) and endophthalmitis 1, 2
• Use a bimanual automated vitrector through a separate pars plana or limbal approach 1
• Avoid pulling or manipulating vitreous strands, as this increases risk of retinal complications 1

Completion of Surgery

Lens Material Management

• Remove all remaining lens material carefully, using lower flow and vacuum settings 1
• If nuclear fragments drop into the vitreous cavity (occurs in 8% of PCR cases), do not attempt retrieval—refer for pars plana vitrectomy by a vitreoretinal specialist 1
• Complete cortical cleanup only if the capsular rim is intact and stable 1

IOL Placement Decision Algorithm

• If anterior capsulorrhexis is intact and sufficient capsular support remains: Place IOL in the capsular bag 1
• If capsular support is compromised but anterior capsule intact: Place IOL in the ciliary sulcus (use 3-piece IOL if available; avoid single-piece acrylic IOLs in sulcus) 1
• If inadequate capsular support: Consider anterior chamber IOL, iris-fixated IOL, or scleral-fixated IOL as primary procedure, or leave aphakic for secondary IOL implantation 1

Postoperative Management and Monitoring

Enhanced Anti-inflammatory Therapy

• Intensify topical corticosteroid regimen beyond standard protocol 1
• Consider topical NSAIDs to reduce risk of CME, which occurs in 5.1% of PCR cases 1
• Monitor for elevated intraocular pressure (IOP), the most common early complication occurring in 33.3% of cases 1

Follow-up Schedule

• Examine within 24 hours postoperatively to assess for corneal edema (occurs in 55.6% of early cases), elevated IOP, and inflammation 1
• Schedule more frequent follow-up visits than routine cataract surgery for at least 1 year 1
• Monitor specifically for persistently elevated IOP (11.1% of late complications) and CME (5.1% of late complications) 1

Long-term Surveillance

• Educate patients about symptoms of retinal detachment, as vitreous loss increases this risk 4
• Perform dilated fundus examination if patient reports new floaters, flashes, or visual field defects 4
• Recognize that despite PCR, mean best-corrected visual acuity can improve from 1.31 logMAR postoperatively to 0.51 logMAR at 1 year with appropriate management 1

Risk Factor Recognition for Prevention

High-Risk Clinical Scenarios

• Pseudoexfoliation syndrome (2.70× increased risk) 1
• Mature cataracts (2.15× increased risk) and brown cataracts (2.44× increased risk) 1
• Posterior polar cataracts (31% PCR rate)—particularly high risk in patients under 40 years of age 5
• Male gender, pre-operative visual acuity <20/200, and nuclear sclerosis grade IV or higher 6

Surgical Technique Modifications

• Consider using an anterior chamber maintainer, though note this increases vitreous loss rate if PCR occurs (72.7% vs 31.6% without maintainer) 3
• In posterior polar cataracts, phacoemulsification has lower PCR rates than extracapsular extraction when performed carefully 5
• Residents have 1.34× higher PCR risk; ensure appropriate supervision 1

Common Pitfalls to Avoid

• Never attempt to retrieve dropped nucleus fragments—this dramatically increases retinal complications and requires vitreoretinal specialist intervention 1
• Do not place single-piece acrylic IOLs in the sulcus—this can cause iris chafing, pigment dispersion, and chronic inflammation 1
• Avoid anterior capsule polishing after PCR—this may destabilize remaining capsular support 4
• Do not underestimate inflammation—PCR cases require more aggressive anti-inflammatory therapy than routine cases 1