• Cataract is broken up with ultrasound and aspirated through an incision of about 0.9 mm.
• It was popularized by ophthalmologist Amar Agarwal as a precursor to modern microincision cataract surgery.
• A very small phaco tip and typically a sleeveless infusion system are used.
• The intraocular lens may require a separate or enlarged incision for implantation, depending on lens type.

• Smaller wound
• Less surgically induced astigmatism
• Faster wound healing and visual rehabilitation

• More technically demanding
• Greater concern for wound heating, fluidic instability, and corneal endothelial stress if parameters are not carefully controlled
• Current cataract practice more commonly refers to this category as microincision cataract surgery (MICS) rather than Phaconit.

How it is implanted

1. Cataract is removed by bimanual/sleeveless phaco through about a 0.9 mm corneal incision.
2. The capsular bag is filled with viscoelastic.
3. The rollable IOL is loaded into a dedicated injector.
4. The IOL is inserted into the capsular bag through a slightly enlarged incision, usually about 1.2 to 1.3 mm.
5. Inside the bag, the lens unrolls and its haptics open to hold it in position.

Which IOL type?

• Original Phaconit: ultra-thin rollable, foldable PCIOL, such as ThinOptX.
• It used a very thin Fresnel-type optic design so it could pass through a sub-1.5 mm incision.
• If a standard hydrophilic/hydrophobic acrylic foldable IOL is used, the incision must generally be enlarged, for example to about 2.2 to 3.2 mm, depending on the lens and injector. That is no longer true sub-millimetre Phaconit IOL implantation.

Posterior Capsule Rupture (PCR) During Cataract Surgery

Predisposing factors

Preoperative

• Dense brunescent or posterior polar cataract
• Posterior polar cataract, due to a pre-existing thin or defective posterior capsule
• Pseudoexfoliation syndrome, zonular weakness
• Small pupil
• High myopia, deep anterior chamber
• Previous vitrectomy
• Trauma, subluxated lens, phacodonesis
• Previous intraocular surgery
• Mature/hypermature cataract
• Poor red reflex or corneal opacity

Intraoperative

• Forceful hydrodissection, especially in posterior polar cataract
• Deep sculpting or excessive phaco energy near the posterior capsule
• Post-occlusion surge
• Sudden movement of the patient or eye
• Inappropriate fluidics or high vacuum
• Pulling cortex peripherally rather than centrally
• Capsulorhexis extension posteriorly
• Zonular dialysis with instability of the capsular bag

Recognition of PCR

• Sudden deepening or instability of the anterior chamber
• Sudden pupillary snap or change in pupil size
• Sudden loss of nuclear followability
• Excessive movement, tilting, or descent of the nucleus
• A visible flap, hole, or linear tear in the posterior capsule
• Appearance of vitreous strands in the anterior chamber or wound
• Persistent shallowing of the chamber despite infusion
• Sudden difficulty aspirating cortex
• Lens fragments falling posteriorly

Principles of Management

1. Do not extend the tear.
2. Maintain a stable anterior chamber.
3. Prevent vitreous traction and remove prolapsed vitreous.
4. Safely deal with remaining lens matter.
5. Choose an IOL only after assessing capsular support.
6. Close wounds securely and monitor for complications.

Immediate Management When PCR Occurs

1. Stop phacoemulsification and aspiration

• Stop ultrasound and aspiration immediately.
• Do not abruptly withdraw the phaco probe, because this can collapse the anterior chamber, enlarge the rent, and draw vitreous forward.

2. Stabilize the anterior chamber with OVD

• Inject a dispersive ophthalmic viscosurgical device (OVD) through a side port, ideally before withdrawing the phaco probe.
• The OVD acts as a barrier between anterior segment contents and vitreous, tamponades the vitreous face, and helps prevent posterior loss of lens fragments.
• Withdraw the phaco probe only after the chamber is stable.

3. Assess the situation

• Size, location, and configuration of the capsular tear
• Presence or absence of vitreous prolapse
• Amount and type of residual lens matter
• Whether any nuclear fragment has fallen into the vitreous
• Integrity of the anterior capsulorhexis and remaining capsular support

Management According to the Intraoperative Situation

A. PCR without vitreous loss

Management

• Keep the chamber formed with dispersive OVD.
• Avoid over-hydrating the vitreous or directing irrigation through the rent.
• If residual nuclear material is small and anterior, it may be carefully removed using low fluidic settings, low bottle height, low aspiration flow, and low vacuum.
• Remove residual cortex gently, directing traction toward the tear rather than pulling away from it.
• A manual aspiration cannula with irrigation off may be useful for residual cortex under OVD protection.
• Refill the capsular bag/sulcus with OVD before placing the IOL.

B. PCR with vitreous prolapse

Do not

• Do not pull, sweep, or aspirate vitreous using the phaco probe or I/A handpiece.
• Do not use a cellulose sponge to pull vitreous out of the eye.
• Do not leave vitreous incarcerated in the wound.
• Do not continue cortical aspiration until vitreous has been dealt with.

Anterior vitrectomy

Preferred technique

• Infusion is delivered through an anterior chamber maintainer or a separate side-port infusion cannula.
• The vitrector enters through a separate paracentesis or through pars plana in an appropriately trained surgeon’s hands.
• Use high cut rate and low vacuum/aspiration to minimize vitreoretinal traction.
• Keep the cutter posterior to the iris plane when feasible.
• Direct the cutter port upward, toward the cornea, rather than engaging vitreous posteriorly.
• Use short, controlled movements.
• Avoid irrigation through the vitrector near the posterior capsular defect because this may hydrate and push more vitreous forward.

• Anterior chamber
• Pupillary margin
• Iris surface
• Main incision and side ports

Confirming vitreous removal

• A round pupil
• Iris falling back normally
• No visible stained vitreous
• No vitreous at the wounds
• No peaking or distortion of the pupil after wound hydration

C. Management of residual cortex

• Re-form the chamber with OVD.
• Remove cortex carefully with low-flow settings or dry/manual aspiration.
• Aspirate cortex toward the capsular rent, not away from it, to avoid extending the tear.
• It is safer to leave a small amount of peripheral cortex than to create severe vitreous traction or enlarge the rent.
• Residual cortex may be managed postoperatively with topical steroids and IOP control if needed.

D. Residual nuclear fragment in the anterior chamber

Small or moderate fragment

• Stabilize it with a dispersive OVD barrier.
• Bring it anteriorly and emulsify only if it can be done safely, with low fluidic settings and away from the rent.
• Alternatively, enlarge the incision and remove it by visco-expression or an irrigating vectis, depending on surgeon experience and fragment density.

Large or unstable fragment

• Consider conversion to manual small-incision cataract surgery or extracapsular cataract extraction.
• Avoid aggressive phaco maneuvers near the rent.

E. Dropped nucleus or retained lens fragments in the vitreous

• Do not chase it with the phaco probe, I/A probe, or anterior vitrector.
• Remove anterior segment vitreous with a thorough anterior vitrectomy.
• Clear accessible cortical material safely.
• Place an IOL only if appropriate support is present.
• Secure all wounds with sutures if required.
• Refer for vitreoretinal assessment and pars plana vitrectomy (PPV) for significant retained lens material.

IOL Implantation After PCR

1. In-the-bag IOL

• PCR is small and stable
• Capsular bag remains intact enough
• There is no significant vitreous loss
• The IOL haptics can be oriented away from the tear

2. Sulcus IOL with optic capture

• Implant a three-piece posterior chamber IOL in the ciliary sulcus.
• Capture the optic posteriorly through the anterior capsulorhexis.
• This improves centration and stability, and reduces the risk of later decentration.

3. Avoid a single-piece acrylic IOL in the sulcus

4. No adequate capsular support

• Consider scleral-fixated or iris-fixated IOL when conditions and expertise permit.
• Alternatively, leave the eye aphakic and perform secondary IOL implantation after the eye is quiet.

Wound Closure and End of Surgery

• Confirm complete removal of vitreous from the anterior segment and wounds.
• Use triamcinolone if needed.
• Check pupil configuration. A peaked pupil suggests residual vitreous traction.
• Remove OVD adequately while avoiding vitreous traction.
• Hydrate wounds cautiously.
• Suture the main incision if there is any doubt about wound security.
• Check IOP, chamber depth, centration of IOL, and wound integrity.
• Consider intracameral antibiotic prophylaxis according to the surgeon’s institutional protocol.

Postoperative Management

Monitoring

• Corneal oedema
• Anterior chamber cells/flare
• Wound leak
• IOP elevation
• Retained lens matter
• IOL centration
• Cystoid macular oedema
• Retinal tear or detachment
• Endophthalmitis

Medical treatment

• Topical corticosteroid, often more intensive than after uncomplicated surgery
• Topical antibiotic per local protocol
• Cycloplegic if marked inflammation is present
• IOP-lowering medication when IOP is raised
• NSAID drops when appropriate to reduce risk of CMO

Retinal assessment

Complications of PCR

Early

• Vitreous loss
• Dropped nucleus/lens fragments
• Corneal oedema
• Raised IOP
• Wound leak
• Inflammation/uveitis
• IOL malposition

Late

• Cystoid macular oedema
• Retinal tear and rhegmatogenous retinal detachment
• Chronic uveitis
• Secondary glaucoma
• Posterior capsular opacification
• IOL decentration or dislocation
• Endophthalmitis

Exam Answer: One-Minute Management Sequence