In the two cases of posterior polar cataract shown here, the posterior capsule split occurs and the anterior hyaloid face remains intact without vitreous prolapse. These two surgeons still are able to implant a toric IOL in the capsular bag with extreme caution.
First, ensure that the capsular rupture is stable—convert to a posterior continuous curvilinear capsulorhexis (PCCC) if possible to prevent radial extension. Avoid hydrodissection, use gentle hydrodelineation, and proceed with controlled phacoemulsification. If cortical cleanup is complete and zonular support is intact, a toric IOL can be carefully placed in the bag, aligning it precisely with the calculated axis. The IOL must be well-centered and rotationally stable. However, if the tear is large, unstable, or vitreous is present, sulcus placement with or without optic capture through an intact anterior capsulorhexis may be safer. Single-piece acrylic toric IOLs cannot be placed in the sulcus, so consider a non-toric IOL instead with postoperative refractive correction (glasses, contacts, or laser). Ultimately, intraoperative judgment and anterior vitrectomy skills are essential. A backup non-toric IOL and alternate plan must always be ready.
