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Posterior Capsule Rupture: Step-by-Step Management

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Posterior Capsule Rupture: Step-by-Step Management

Last updated: November 2026

Every cataract surgeon will meet a posterior capsule rupture (PCR). What happens in the next minute decides the outcome. A calm, rehearsed sequence turns a crisis into a routine manoeuvre.

Early signs

  • Sudden deepening of the chamber, or the pupil suddenly dilating.
  • The nucleus tilts, falls back or cannot be rotated; fragments move away from the phaco tip.
  • A clear "red reflex" area or a capsule edge seen; vitreous in the wound or pulling the pupil (peaking).

Immediate steps

  1. Do not pull the phaco probe out: stop phaco power, keep irrigation, and inject dispersive viscoelastic through the side port before withdrawing, to keep the chamber formed and push vitreous back.
  2. Lower the bottle height, and assess the size of the tear and whether vitreous has come forward.
  3. Protect the remaining nucleus: viscoelastic underneath it, a lens glide or a sheets glide; remove large pieces with low flow, or convert to a larger incision and express.
  4. Never chase a nucleus that has fallen into the vitreous: leave it for a vitreoretinal surgeon.

Anterior vitrectomy

  • Bimanual (separated infusion and cutter) through side ports is preferred to coaxial.
  • High cut rate, low vacuum and flow; keep the cutter behind the capsule plane.
  • Stain vitreous with preservative-free triamcinolone to see it.
  • Clear vitreous from the wounds and anterior chamber; check the pupil is round at the end.

IOL options

Capsule statusIOL choice
Small, round PCR with intact capsulorhexisOne-piece IOL in the bag (gently)
Larger tear, intact rhexisThree-piece IOL in the sulcus with optic capture through the rhexis (keep the power for the bag); without capture, reduce power by about 0.5–1.0 D
No capsule supportAnterior chamber IOL, iris-claw IOL, or scleral-fixated IOL (for example Yamane), now or as a second procedure
NeverA one-piece acrylic IOL in the sulcus (pigment dispersion, UGH syndrome)

After surgery

  • Suture the main wound if in doubt; check IOP.
  • Intensive topical steroid and NSAID (CME risk), consider intracameral antibiotic per protocol; watch IOP.
  • Explain honestly to the patient; warn about retinal detachment symptoms; dilated retinal examination.
  • Refer early to vitreoretinal colleagues for retained lens matter.

Where residents slip

  • Pulling the phaco tip out before filling with viscoelastic.
  • Chasing a dropped nucleus.
  • Putting a single-piece acrylic IOL in the sulcus.
  • Leaving vitreous in the wound.

Test yourself: flip cards

Related: Phaco Tips & Tricks, Posterior Capsule Opacification, Nd:YAG Capsulotomy and IOL Dislocation, Endophthalmitis: Types, Organisms and Management.

Key sources

  • Chakrabarti A, Nazm N. Posterior capsular rent: prevention and management. Indian J Ophthalmol. 2017;65:1359-1369
  • Royal College of Ophthalmologists. Cataract Surgery Guidelines (current)

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Written by Dr. Dhaval Patel, MD (Ophthalmology, AIIMS New Delhi)

Consultant, Cataract & Refractive Surgery — among a small number of AIIMS-trained ophthalmologists practicing in Gujarat. Read full credentials & experience or view his 28 publications on ResearchGate.

📚 Also the author of OKAT Decoded and other high-yield ophthalmology exam-prep books used by residents and PG aspirants.

Looking for an eye specialist in Ahmedabad? Learn about our Eye Department or book a consultation with Dr. Dhaval Patel.

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