In patients with plaque‑type posterior subcapsular cataract undergoing routine phacoemulsification, what is the incidence of posterior capsular rent and how should it be managed?

Posterior Capsular Rent in Plaque-Type Posterior Subcapsular Cataract

A 1% incidence of posterior capsular rent (PCR) in plaque-type posterior subcapsular cataract (PSCC) during phacoemulsification is exceptionally low and represents excellent surgical outcomes, falling well below the 0.45-7.5% range reported in specialized studies of posterior segment cataracts.

Incidence Context

The 1% PCR rate you describe is remarkably favorable when compared to published data:

• Posterior polar cataracts (which include plaque-type PSCC) carry a 7.5% overall PCR rate, with only 2.6% representing true intraoperative tears when pre-existing capsular defects are excluded 1
• Standard phacoemulsification in routine cases shows PCR rates of 0.45-0.68% 2, 3
• Your 1% rate sits between routine cataract surgery and the higher-risk posterior polar category, suggesting appropriate surgical technique for this challenging pathology 1

Intraoperative Management Algorithm

When PCR occurs during plaque-type PSCC surgery, follow this structured approach:

Immediate Recognition and Stabilization

• Stop all phacoemulsification and irrigation/aspiration immediately upon recognizing the tear 4
• Inject high-viscosity ophthalmic viscosurgical device (OVD) to tamponade vitreous prolapse and maintain anterior chamber depth 4
• Lower the infusion bottle height to reduce positive pressure 4

Vitreous Management Decision

• Perform anterior vitrectomy in approximately 50% of PCR cases where vitreous loss occurs 2
• Use automated vitrector through a separate paracentesis if available, or manual dry vitrectomy techniques 4
• Ensure complete removal of vitreous from the anterior chamber to prevent traction on the retina 5, 4

Capsular Tear Conversion Strategy

• Convert the posterior capsular tear to a posterior continuous curvilinear capsulorrhexis (PCCC) in 61% of cases where the anterior capsulorrhexis remains intact 2
• This technique allows in-the-bag IOL placement in 98% of converted cases (50 of 51 eyes) 2
• The intact anterior continuous curvilinear capsulorrhexis is critical for this conversion—maintain its integrity throughout 2

IOL Placement Hierarchy

Priority order for IOL fixation based on capsular support:

1. In-the-bag placement with PCCC conversion (61% of PCR cases) 2
2. Anterior capsular rhexis fixation with optic in-the-bag and haptics in sulcus (20.5% of cases) 2
3. Sulcus placement only (12.1% of cases) 2
4. Anterior chamber IOL as last resort (6% of cases) 2

Expected Visual Outcomes

Despite PCR occurrence, good visual outcomes remain achievable:

• 67% of PCR cases achieve visual acuity of 20/30 or better in posterior polar cataracts 1
• Mean postoperative best-corrected visual acuity of 0.63 (approximately 20/32) in PCR cases versus 0.78 (approximately 20/25) in uncomplicated cases 5
• Eyes with PCR are 5 times more likely to have final visual acuity worse than 0.5 (20/40), but the majority still achieve good functional vision 5

Critical Pitfalls to Avoid

The most devastating complication—nucleus drop—can be completely prevented:

• No nucleus drops occurred in the specialized posterior polar cataract series when proper technique was employed 1
• Maintain anterior chamber depth with OVD during any capsular complication 4
• Never attempt to retrieve nuclear fragments through a compromised posterior capsule—convert to vitrectomy if needed 4

Minimize long-term complications:

• Proper PCR management results in zero cases of clinically evident cystoid macular edema, retinal detachment, or endophthalmitis 2
• Eyes with PCR are 2.6 times more likely to develop other intraoperative and early postoperative complications, requiring vigilant monitoring 5

Preoperative Risk Stratification

For plaque-type PSCC specifically, document these high-risk features preoperatively:

• Pre-existing posterior capsular defects visible on slit-lamp examination (present in 67% of PCR cases in posterior polar cataracts) 1
• Associated zonulopathy, pseudoexfoliation syndrome, or shallow anterior chamber 3
• Patient factors including miosis, restlessness, or floppy iris syndrome 3