Lens Capsule Rupture (Capsular Break) and Management

Key Points at a Glance

Key Points at a Glance

• Posterior capsule rupture is a break in the posterior lens capsule during cataract surgery and is one of the most common intraoperative complications.
• The incidence rate is 1–2% for standard surgeons and up to 14% for inexperienced surgeons.
• High-risk factors that should be identified preoperatively include posterior polar cataract (incidence 15–30%), pseudoexfoliation syndrome, and eyes with prior vitrectomy.
• Early recognition is crucial. Do not miss signs of capsule rupture (e.g., sudden tilting of the nuclear fragment, abrupt loss of suction).
• If capsule rupture is noticed, immediately stop ultrasound, fill the anterior chamber with viscoelastic material, and then withdraw the tip.
• Treatment involves three steps: removal of residual nucleus, anterior vitrectomy, and IOL fixation.
• If sulcus fixation is needed, do not insert a one-piece acrylic IOL into the ciliary sulcus. Use a three-piece acrylic IOL.

1. What is posterior capsule rupture?

Posterior capsule rupture (PCR) is a tear in the posterior capsule that occurs during cataract surgery. It is one of the most common intraoperative complications in cataract surgery.

When the posterior capsule is ruptured, the barrier between the anterior and posterior chambers is lost, creating a risk of vitreous prolapse into the anterior chamber. If vitreous loss occurs, the risk of serious postoperative complications such as nucleus drop, tractional retinal tear, and endophthalmitis increases significantly.

In recent years, the incidence of PCR has decreased considerably due to improvements in cataract surgery equipment. The incidence varies greatly depending on the surgeon’s experience. It is reported to be within 1–2% for standard surgeons, 0.45–3.6% for experienced surgeons, 0.8–8.9% for residents, and 4.8–11% for surgeons newly transitioning to phacoemulsification. In high-risk cases such as vitrectomized eyes, it can rise to 9% ¹⁾.

It has been reported that the risk of posterior capsule rupture increases fourfold in cases of unsuccessful continuous curvilinear capsulorhexis (CCC) ³⁾.

Q Can vision recover even if posterior capsule rupture occurs?

A

If managed appropriately, visual function is often unaffected. However, the risk of postoperative complications such as nucleus drop, endophthalmitis, retinal detachment, and cystoid macular edema increases, requiring careful follow-up. It may also take time for postoperative visual improvement.

2. Main Symptoms and Clinical Findings

Subjective Symptoms

Posterior capsule rupture is a condition recognized intraoperatively by the surgeon, not by the patient. The greatest challenge is for the surgeon not to miss the signs of capsular rupture.

Patients under local anesthesia can sense the surgeon’s movements during the procedure. They may feel that “the surgery failed” after the operation, so careful pre- and postoperative explanations are important.

Intraoperative Findings (Signs of Capsular Rupture)

Since the posterior capsule cannot be directly visualized during the early to middle stages of nucleus processing, capsular rupture must be suspected based on the following indirect signs.

• A transparent area appears in the pupillary zone: When the posterior capsule is damaged, part of the visual field appears transparent.
• The anterior chamber suddenly deepens and the nucleus tilts: The pressure balance changes due to posterior capsule rupture.
• A nuclear fragment suddenly tilts or sinks significantly: Indicates prolapse toward the vitreous cavity.
• The nuclear fragment stops coming toward the ultrasound tip: a sudden decrease in suction is felt
• Vitreous becomes entangled in the tip and aspiration worsens: a sign that vitreous has prolapsed into the anterior chamber
• The pupil is drawn into an oval shape: indicates traction due to vitreous prolapse
• A linear posterior capsule edge is visible during irrigation and aspiration: when the torn edge of the posterior capsule can be seen

When nuclear processing is nearly complete, the posterior capsule can be directly visualized, making it easier to confirm a capsular rupture. On the other hand, the earlier the rupture occurs, the more additional maneuvers are required afterward.

Q Why is it important to detect capsular rupture early?

A

If ultrasound manipulation is continued without recognizing capsular rupture, the area of posterior capsule damage expands, and the amount of vitreous prolapsing into the anterior chamber increases. As a result, the risk of nuclear drop or iatrogenic retinal tear due to vitreous traction significantly increases. Early recognition allows subsequent maneuvers to be minimized.

3. Causes and Risk Factors

Causes of Capsular Rupture

The cause of posterior capsule rupture is most often direct contact and damage to the posterior capsule by instruments such as the ultrasound tip, irrigation/aspiration tip, hook, or intraocular lens. By timing of occurrence, it is reported that 48.1% occur during ultrasound oscillation, 31.8% during irrigation/aspiration, and 9.1% during intraocular lens insertion ³⁾.

• During nuclear division: Excessive force causes zonular rupture or posterior capsule tear
• During phacoemulsification: The ultrasound tip directly contacts the posterior capsule, causing a round capsular rupture
• During irrigation/aspiration: The tip inadvertently aspirates the posterior capsule (aspiration rupture, round-shaped capsular break)
• During IOL insertion: The loop or optic pushes the posterior capsule, the posterior capsule rises due to leakage of viscoelastic material, unfolding of a foldable IOL deep within the capsular bag, or sudden ejection by a push-type injector
• During capsulorhexis: A crack from continuous curvilinear capsulorhexis may extend to the posterior capsule³⁾

Risk Factors

Risk factors for posterior capsule rupture are classified into patient-related, surgeon-related, and equipment-related factors^{1, 2)}.

Patient-Related Risks

Posterior polar cataract: Due to structural weakness of the posterior capsule, the incidence of capsular rupture is high, historically around 30% and currently around 15%.

Exfoliation syndrome: Associated with weakened zonules, poor pupil dilation, and a thick, fibrotic posterior capsule.

Post-vitrectomy eye: Lack of vitreous support makes the posterior capsule unstable. The incidence of posterior capsule rupture increases up to 9%¹⁾.

High myopia (axial length >26 mm): Prone to the trampoline phenomenon of the posterior capsule¹⁾.

Brown or white cataract: The nucleus is hard and visibility is reduced¹⁾.

Small pupil: Reduces working space and visibility. Be aware of history of alpha-1 blocker use (e.g., tamsulosin)¹⁾.

Surgeon/Equipment-Related Risks

Inexperienced surgeon: Incidence is higher in resident surgeries¹⁾.

Unfamiliar equipment or inappropriate device settings: Surge is more likely to occur.

Unsuccessful continuous curvilinear capsulorhexis: If a tear occurs in the capsulotomy, the risk increases fourfold³⁾.

Shallow or deep anterior chamber: Leads to anterior chamber instability, increasing surgical difficulty²⁾.

Chronic obstructive pulmonary disease, obesity, advanced age: Difficulty maintaining supine position, prone to intraocular pressure fluctuations²⁾.

Preoperative measures for high-risk cases

It is important to identify cases at high risk of posterior capsule rupture preoperatively. If posterior polar cataract is suspected, confirm the location, shape, size, and bilaterality of the opacity. If zonular weakness is suspected, check for lens tremors in sitting and supine positions, and for asymmetry in anterior chamber depth.

4. Diagnosis and examination methods

Proper preoperative evaluation is the first step in preventing posterior capsule rupture.

Preoperative evaluation

Evaluation item	Confirmation content
Medical history	History of ocular trauma, surgery, and use of medications such as alpha-1 blockers
Slit-lamp examination	Corneal clarity, anterior chamber depth, integrity of anterior and posterior capsules
Zonular assessment	Presence of lens phacodonesis, attachment of exfoliation material

• Posterior capsule fragility assessment: Differentiation of posterior polar cataract (well-defined white discoid opacity near the center of the pupil under the posterior capsule, diameter 1.8–3.0 mm) is particularly important.
• Specular microscopy: Confirmation of corneal endothelial cell density (hard cataract, surgical history, elderly patients).
• Dilated fundus examination: Posterior segment evaluation.
• Confirmation of continuous curvilinear capsulorhexis (CCC) remnant: Whether the CCC remains intact intraoperatively directly determines the IOL fixation method.
• Anesthesia method consideration: Consider retrobulbar anesthesia for patients with significant anxiety.

Differential Diagnosis

• Pre-existing posterior capsule rupture: Damage present before surgery due to trauma or previous surgery
• Zonular dehiscence: Shares pathophysiology but management differs. Main signs are lens displacement and phacodonesis
• Congenital capsular defect in posterior polar cataract: May lack capsular support preoperatively
• Intraoperative shallow anterior chamber syndrome: Perform immediate fundus examination to differentiate from acute choroidal effusion

Intraoperative continuous assessment

During phacoemulsification, maintain a low threshold for suspecting capsular rupture and always watch for signs of capsular break. When the irrigation/aspiration tip inadvertently aspirates the posterior capsule, linear converging wrinkles (spider sign) may appear on the posterior capsule. In such cases, immediately release using the foot pedal reflux function.

5. Standard Treatment

Treatment during capsule rupture consists of three steps: (1) removal of residual nucleus, (2) anterior vitrectomy (plus removal of residual cortex), and (3) intraocular lens fixation.

Initial Response to Capsule Rupture (“Do’s and Don’ts”)

If capsule rupture is identified, adhere strictly to the following:

• Immediately stop ultrasound operation
• Do not immediately withdraw the ultrasound tip (risk of anterior chamber collapse → increased vitreous prolapse)
• Do not aspirate the vitreous with ultrasound (vitreous cannot be cut by ultrasound)
• Do not perform excessive anterior vitrectomy when nuclear fragments remain

Correct procedure: Inject viscoelastic material through the side port to completely fill the anterior chamber → lower the bottle to confirm that the viscoelastic material has filled properly → then withdraw the tip.

Step 1: Removal of residual nucleus

Select the following method based on the size of the nucleus and the extent of capsular rupture. Since the anterior vitrectomy cutter may preferentially cut the vitreous when nucleus and vitreous are mixed, causing nuclear fragments to fall onto the fundus, it is a principle to always remove nuclear fragments before Step 2.

Method	Indication	Advantage	Disadvantage
Viscoexpression method	Nuclear fragments ≤1/2, small posterior capsule rupture with nucleus in anterior chamber	Minimal tissue damage, no wound enlargement needed, low intraocular pressure fluctuation	Not suitable for large nuclei
Expression method (loop spatula/hook)	Large hard nucleus, tilted nucleus	Can handle large nuclear fragments	Requires wound enlargement to nearly 180°, risk of expulsive hemorrhage

The viscoexpression method involves injecting viscoelastic material in front of and behind the nuclear fragment while depressing the scleral side of the wound to express the nucleus. It is recommended as the “nucleus delivery technique with the least tissue damage.” If the capsulorhexis is small and peripheral, continuing PEA while maintaining the anterior chamber with viscoelastic material is also an option ⁴⁾.

Step 2: Anterior vitrectomy

Using the anterior vitreous cutter and infusion needle attached to the cataract surgery device, sufficiently resect the anterior vitreous 180 degrees opposite from both corneal side ports. Set the cutter to aspiration priority mode to aspirate residual cortex.

• If a large amount of cortex remains, removing the sleeve from the I/A and aspirating with only the tip without infusion is also useful.
• Wipering method: Release incarcerated vitreous at the wound and side ports with a hook, and resect the freed vitreous with the cutter.
• Postoperative intravitreal triamcinolone injection for vitreous visualization improves the accuracy of anterior vitrectomy ¹⁾.
• Vitreous prolapses into the anterior chamber due to damage to the anterior hyaloid membrane ^{6, 7)}

At the end of surgery, induce miosis and confirm that vitreous is not incarcerated in the wound or side port. If the pupil is not round, excise the incarcerated vitreous.

Step 3: Intraocular Lens Fixation

The method of intraocular lens fixation is determined by the condition of the remaining capsule.

• When a continuous curvilinear capsulorhexis rim remains circumferentially: Fix a 3-piece acrylic intraocular lens in the sulcus (ciliary sulcus fixation). Insert a lens with a power 0.5–1.0 D weaker than the planned power. Guide for myopic shift by power: +5.0 to +9.0 D: ±0 D, +9.5 to +17.0 D: -0.5 D, +17.5 to +28.0 D: -1.0 D, +28.5 to +30.0 D: -1.5 D ⁵⁾
• When optic capture is possible: A method where the haptics of a 3-piece acrylic IOL are placed outside the capsule and the optic is captured by the anterior capsulorhexis rim. This results in high stability with almost no decentration, tilt, or iris capture ^{5, 8)}. It is recommended to create a CCC diameter 1.0–2.0 mm smaller than the optic diameter ⁵⁾
• Direction of anterior capsule tear: For tears in the upper direction (9 to 3 o’clock), the long-term prognosis of extracapsular fixation is generally good. For tears in the lower direction, the IOL tends to shift downward over time.
• Posterior capsule CCC method: In cases of punch-out capsular rupture during irrigation/aspiration, perform posterior capsule CCC with anterior capsule forceps to connect the tear into a circle, which may allow IOL in-the-bag insertion.
• When capsular damage is extensive: IOL scleral suturing or intrascleral fixation (flanged intrascleral fixation) is indicated ¹⁾. The procedure is complex and has a high complication rate, so it should be handled by an experienced surgeon.

Precautions in IOL selection

When extracapsular fixation is required, a 1-piece (1P) acrylic IOL should not be fixed in the extracapsular (ciliary sulcus) position. A report found that among 30 eyes with complications related to ciliary sulcus fixation of 1P acrylic IOLs, 28 eyes (93%) required surgery, and 25 eyes (83%) underwent IOL exchange ⁵⁾. Main complications include IOL dislocation, iris chafing, pigment dispersion, elevated intraocular pressure, and cystoid macular edema. For extracapsular fixation, always use a 3-piece acrylic IOL.

Goals

During capsulorhexis surgery, aim to achieve all of the following goals.

• Do not drop nuclear fragments into the vitreous cavity.
• Do not create iatrogenic retinal tears.
• Do not leave behind epinucleus or cortex.
• Ensure central fixation of the intraocular lens.
• Do not incarcerate prolapsed vitreous in the wound.
• Confirm miosis and a round pupil
• Because the risk of postoperative endophthalmitis increases, consider wound suturing and carefully follow up

Q What should be done if the nucleus falls into the vitreous cavity?

A

A dropped nucleus cannot be removed through the anterior chamber and requires 3-port vitrectomy via the pars plana. Leaving the dropped nucleus increases the risk of endophthalmitis ⁴⁾, retinal detachment ⁴⁾, and cystoid macular edema ⁴⁾, so refer to a vitreoretinal surgeon as early as possible. Small nuclear fragments or cortical fragments smaller than half a disc diameter may be absorbed spontaneously, but since floaters remain, removal is preferable whenever possible.

6. Pathophysiology and Detailed Mechanism

Anatomical Weakness of the Posterior Capsule

The posterior capsule is an elastic basement membrane composed of type IV collagen and glycosaminoglycans produced by lens epithelial cells. It is approximately 20 microns thick in the anterior and posterior equatorial zones, but extremely thin at 2 to 4 microns at the central posterior pole. This structural characteristic makes the posterior capsule prone to rupture.

The thickness of the posterior capsule decreases with age (except at the posterior pole), increasing the risk of rupture in elderly individuals. Additionally, in posterior polar cataracts, the posterior capsule around the opacity is structurally weak, and some cases already have spontaneous posterior capsule rupture before surgery.

Intraoperative Pressure Dynamics and Capsular Rupture

When posterior capsule rupture occurs, the pressure balance between the anterior and posterior chambers changes abruptly. If the anterior hyaloid membrane is damaged, vitreous begins to prolapse into the anterior chamber ^{6, 7)}. At this point, continuing ultrasonic manipulation leads to the following chain of events.

1. Rapid enlargement of the rupture area
2. Increased vitreous prolapse into the anterior chamber
3. Sudden increase in nuclear drop risk
4. Iatrogenic retinal tear due to vitreous traction

Rapid withdrawal of the tip causes anterior chamber collapse, leading to further anterior migration of vitreous and enlargement of the posterior capsule rupture.

Special mechanisms in posterior polar cataract

Posterior polar cataract is characterized by structural fragility of the posterior capsule at the opacity. When the phaco tip or irrigation/aspiration tip is withdrawn from the incision, the anterior chamber suddenly shallows due to vitreous pressure, and posterior capsule rupture is likely to occur. Therefore, before withdrawing the tip, the anterior chamber must be completely replaced with an ophthalmic viscosurgical device. Hydrodissection is contraindicated; the technique of separating the nucleus and epinucleus by hydrodelineation and using it as a cushion enhances safety.

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7. Latest Research and Future Prospects (Research Stage Reports)

For Patients: Please Read Carefully

The following content is currently in the research stage or under clinical trials and is not standard treatment available at general hospitals. It is reference information for professionals regarding future medical developments.

Femtosecond Laser-Assisted Cataract Surgery

Femtosecond laser-assisted cataract surgery is considered to enable safer and more precise capsulotomy in intumescent cataracts with a high risk of posterior capsule rupture. However, cases of capsular block syndrome associated with femtosecond laser-assisted capsulotomy have been reported, requiring caution ¹⁾.

Triamcinolone Injection for Intraoperative Vitreous Visualization

A technique that visualizes the vitreous in white by injecting triamcinolone into the anterior chamber has been reported to contribute to improved accuracy of anterior vitrectomy ¹⁾. Its usefulness as an auxiliary technique in situations where it is difficult to visualize the transparent vitreous has been evaluated.

Widespread Use of Sutureless Flanged Intrascleral Fixation

The widespread use of a secondary IOL implantation method that fixes a flanged PVDF haptic into the sclera without sutures has enabled stable IOL fixation in cases without capsular support. Complications such as elevated intraocular pressure, IOL tilt, vitreous hemorrhage, cystoid macular edema, conjunctival erosion over the fixation site, and endophthalmitis have been reported ¹⁾, and accumulation of data on long-term outcomes is expected.

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8. References

1. Miller KM, Oetting TA, Tweeten JP, et al. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022;129(1):P1-P126. PMID:34780842. https://pubmed.ncbi.nlm.nih.gov/34780842/
2. National Institute for Health and Care Excellence. Cataracts in adults: management. NICE guideline NG77. https://www.nice.org.uk/guidance/ng77
3. Keles A, Sen E, Altas FB, Elgin U. Risk factors for posterior capsule rupture in mature cataract surgery: a study of 1302 cases. Indian J Ophthalmol. 2023;71(1):113-118. doi:10.4103/ijo.IJO_1633_22. https://pmc.ncbi.nlm.nih.gov/articles/PMC10155587/
4. Park J, Lee S, Kim J. Clinical outcomes of management of posterior capsule rupture with air bubble techniques. Int J Ophthalmol. 2020;13(12):2007-2011. doi:10.18240/ijo.2020.12.24. https://pmc.ncbi.nlm.nih.gov/articles/PMC7708370/
5. Zhao J, Yu J, Wang T, Mban B. Ciliary sulcus implantation of intraocular lens in manual small incision cataract surgery complicated by large posterior capsule rupture. Exp Ther Med. 2019;17(2):1470-1475. doi:10.3892/etm.2018.7074. https://pmc.ncbi.nlm.nih.gov/articles/PMC6327667/
6. Torii H, Takahashi K, Yoshitomi F, et al. Mechanical detachment of the anterior hyaloid membrane from the posterior lens capsule. Ophthalmology. 2001;108(12):2182-2185.
7. Kawasaki S, Suzuki T, Yamaguchi M, et al. Disruption of the posterior chamber-anterior hyaloid membrane barrier during phacoemulsification and aspiration as revealed by contrast-enhanced magnetic resonance imaging. Arch Ophthalmol. 2009;127(4):465-470.
8. Tian T, Chen C, Jin H, et al. Capture of intraocular lens optic by residual capsular opening in secondary implantation: long-term follow-up. BMC Ophthalmol. 2018;18(1):84.