Prevent posterior extension of a capsular break

This is a resident case that you really must learn from, even if you are an expert. During nucleus removal the anterior capsular rim is damaged and this break extends out to the equator of the capsular bag. How can we prevent this rip from extending to the posterior capsule?

In this case the patient is a high myope and we are implanting a +6.0 diopter lens but more importantly, the patient has a high degree of corneal astigmatism and really needs to have this toric IOL. In the USA, there are no toric IOLs which are designed for placement in the sulcus. So we really need to ensure that the rest of the capsular bag stays intact to receive this toric IOL.

The key is to prevent the anterior chamber from collapsing or depressurizing during the rest of the surgery. Then the IOL must be carefully placed in the correct position without causing stress on the capsule. Finally, viscoelastic must be removed while keeping the anterior chamber formed.

Click below to learn from this excellent resident training case:


  1. 1. Could you have used microinsturments when you saw the small knick to properly enlarge the capsulorhexis so that it did not extend further?
    2. Could the extension have been prevented if you filled with bag prior to removing the I+A tip the first time?
    3. I didn’t see the OVD removed at the end – how did you handle this?
    Thank you!!!

  2. I had a similar case where I placed a monofocal lens in the capsule with an anterior rent in a patient with high myopia. I left the haptics approximately 90 degrees away from the rent but on POD#1 one of the haptics was rotated into the rent and the optic is decentered nasally. Would you suggest attempting to rotate the lens away from the rent or would you consider a lens exchange with a three piece lens in the sulcus.

    1. I would exchange for a three piece IOL in the sulcus. I have a video of that coming up next week here on CataractCoach

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