3060: your first posterior capsule rupture – you are doing it WRONG!
A posterior capsule rupture is an inevitable learning landmark in every surgeon’s career, but managing the complication correctly is what separates a transient misstep from a compounding disaster. In this teaching case, a series of critical errors demonstrates exactly what not to do when capsule integrity is lost:
- Aggressive Epinuclear Aspiration: Overly aggressive vacuum during epinuclear removal engaged and tore the delicate posterior capsule.
- Abrupt Phaco Removal: Pulling the phaco handpiece straight out of the eye caused a sudden drop in intraocular pressure, encouraging vitreous to prolapse forward into the anterior chamber.
- Inadequate Anterior Vitrectomy: The anterior vitrectomy was incomplete, leaving vitreous strands incarcerating the main incision and anterior segment.
- Omitting Triamcinolone: Failure to instill preservative-free triamcinolone acetonide meant prolapsed vitreous went unstained, making thorough visualization and clean-up nearly impossible.
- Residual Cortical Material: Substantial cortex was left behind, predisposing the eye to severe post-operative inflammation and secondary pressure spikes.
- Single-Piece IOL in the Sulcus: Placing a single-piece acrylic lens directly into the sulcus—rather than a three-piece lens—creates high risk for mechanical iris chafing, pigment dispersion, and UGH syndrome.
Analyzing these compounding mistakes provides an invaluable blueprint for bailout protocols, highlighting the vital need to pause, fill with OVD before withdrawal, stain vitreous, perform a bimanual vitrectomy, and choose the correct lens geometry. Watch the video to break down every step of this complication cascade.
What is the very first step you instruct a trainee to do the moment a posterior capsule break is identified? Please comment your teaching pearls below.
