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Cover Focus | May/June '19

Staging a Rescue

Anterior capsular tears are a common complication of cataract surgery that can occur during any step of the procedure. Primary anterior capsular tears occur during capsulorhexis creation, and secondary anterior capsular tears occur after the capsulorhexis has been completed. Primary anterior capsular tears are commonly seen in the setting of intumescent white cataracts, pseudoexfoliation, and pediatric cataracts.

IIf an anterior capsular tear occurs while the surgeon is attempting a continuous curvilinear capsulorhexis and is visible at the edge of the capsule and not beyond the pupil margin, different rescue maneuvers can be performed, such as regrasping the flap and redirecting the forces acting against the tear. In the setting of an anterior capsular tear that extends beyond the pupil margin, careful evaluation of the tear should be performed to determine if it remains pre-equatorial or if the posterior capsule has been compromised.

Indications that the tear has extended out to the posterior capsule include: (1) deepening of the anterior chamber, (2) the pupil snap sign, (3) sudden appearance of a red reflex peripherally, (4) loss of motility of the flaps, and (5) nucleus tilt or nucleus sink. If the anterior capsular tear is pre-equatorial, phacoemulsification can be still performed, depending on the experience and skill of the surgeon. If needed, conversion to extracapsular cataract extraction or small-incision cataract surgery can be attempted.


In the case highlighted in the Video above, a large anterior capsular tear occurred during the early stages of capsulorhexis creation. It extended beyond the pupil margin with no signs that the posterior capsule was compromised but with a high risk that it could occur.

My first step was to complete the capsulorhexis to enable lens removal. This presented a challenge because the large tear decreased the opposite tension required for the curvilinear technique. In this setting, the can-opener or multipuncture approach—which consist of using the cystotome or a bent needle to make small incisions on both sides of the tear to form an opening in the anterior capsule—may be required.

The second challenge is preventing posterior extension of the tear during phacoemulsification. To this end, hydrodissection should be avoided, and debulking of the nucleus should be performed with hydrodelineation. As shown in the Video, I injected OVD into the capsular bag behind the lens to slightly prolapse the lens into the anterior chamber. I then debulked the lens with a bimanual technique, using both the chopper and OVD cannula.

I inserted a three-piece IOL behind the lens into the sulcus, leaving the trailing haptic outside through the main corneal incision as a precaution in case the tear extended posteriorly and the IOL needed to be rescued due to a lack of capsular support. This approach, described as the scaffold technique, protects the posterior capsule, stabilizes the anterior chamber, and enables phacoemulsification in a deeper plane.

After performing phacoemulsification of the lens at the iris plane and confirming that the capsule was intact, I flipped and repositioned the IOL inside the capsular bag. Residual cortical material was easily removed with irrigation and aspiration around and under the IOL.

Despite the unplanned intraoperative complication, the patient had an excellent outcome.

Maria S. Romero, MD
  • Physician CEO, Precision Eye Care, Baltimore
  • msromemd@gmail.com
  • Financial disclosure: None