• 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

Capsular Tension Rings (CTR) in Cataract Surgery

Basic design

• Made of polymethyl methacrylate (PMMA)
• A thin, flexible, circular open ring
• Has eyelets at its two ends to facilitate insertion, manipulation, or removal
• Inserted into the equator of the capsular bag
• Usually has an expanded diameter of approximately 11 to 13 mm, with variants for small eyes, large myopic eyes, and paediatric eyes

Functions

1. Expands and maintains the circular contour of the capsular bag.
2. Redistributes zonular tension around the entire capsular circumference.
3. Stabilizes the bag during capsulorhexis, phacoemulsification, cortical aspiration, and IOL implantation.
4. Reduces capsular folds and trampolining of the posterior capsule.
5. Helps keep the IOL well centered in the capsular bag.
6. Reduces the risk of progressive intraoperative zonular dialysis.
7. May help reduce late capsular bag contraction and IOL decentration in selected eyes.

Indications

1. Pseudoexfoliation syndrome

• Zonular weakness
• Phacodonesis
• Poor pupillary dilatation
• Capsular bag instability
• Late in-the-bag IOL-capsular bag complex dislocation

2. Traumatic cataract

3. Lens subluxation

• Traumatic subluxation
• Marfan syndrome
• Homocystinuria
• Weill-Marchesani syndrome
• Ectopia lentis
• High myopia with zonular weakness

4. Intraoperative zonular dialysis

• Excessive movement of the capsular bag during capsulorhexis
• Wrinkling of the capsule
• Instability during phacoemulsification
• Localised capsular bag collapse
• Posterior capsule trampolining
• Lens decentration

5. Previous intraocular surgery

• Previous pars plana vitrectomy
• Prior glaucoma surgery
• Previous retinal surgery
• History of complicated cataract surgery in the fellow eye

6. Mature, hypermature, or Morgagnian cataract

7. High axial myopia

8. Intraocular conditions associated with zonular weakness

• Uveitis
• Retinitis pigmentosa
• Previous acute angle-closure attack
• Chronic glaucoma
• Advanced age
• Diabetes, in selected complex cases

Contraindications and Situations Requiring Caution

Relative contraindications

• Posterior capsule rupture: a standard CTR may extend the tear or migrate posteriorly through the defect.
• Large zonular dialysis: standard CTR alone is inadequate when extensive zonular loss is present.
• Severe lens subluxation: a scleral-fixated modified CTR or capsular tension segment is usually needed.
• Uncontrolled capsulorhexis tear: ring insertion can propagate the tear.
• Inadequate capsular bag integrity: placing a CTR in a severely compromised bag can worsen the situation.

Types of Capsular Support Devices

1. Standard CTR

Uses

• Mild diffuse zonular weakness
• Focal dialysis of limited extent
• Pseudoexfoliation
• Mild traumatic zonulopathy
• Mild lens subluxation

Limitation

2. Modified Capsular Tension Ring: Cionni Ring

Indications

• Severe zonular weakness
• Extensive zonular dialysis
• Marked lens subluxation
• Progressive zonulopathy
• Congenital absence of zonules
• Significant traumatic lens subluxation

Advantages

• Provides both circumferential capsular support and scleral fixation.
• Recenters a decentered capsular bag.
• Allows in-the-bag PCIOL implantation if the capsule can be preserved.
• Gives longer-term support when zonular loss is extensive.

3. Capsular Tension Segment (CTS)

Indications

• Localized but marked zonular dialysis
• Focal lens subluxation
• Need for temporary intraoperative support
• When scleral fixation is required in one sector

Advantages

• Can be inserted early in surgery.
• Can be scleral-fixated.
• Produces less stress on the opposite capsule compared with forcing a full ring into an unstable bag.
• May be combined with a standard CTR or another CTS in extensive zonular loss.

Timing of CTR Insertion

• Early insertion improves zonular stability.
• Late insertion makes cortical cleanup easier and may reduce trapping of cortex.

Early insertion

Advantages

• Stabilizes the bag during phacoemulsification.
• Reduces movement of the lens-capsule complex.
• Helps prevent extension of a pre-existing zonular dialysis.
• Useful in marked intraoperative instability.

Disadvantages

• Cortex can become trapped between the ring and capsule.
• Cortical aspiration may become difficult.
• Ring insertion itself may stress the zonules and enlarge the dialysis.
• Insertion can worsen capsular bag subluxation if not performed carefully.

Late insertion

Advantages

• Easier cortical cleanup.
• Less cortex is trapped behind the ring.
• Reduced manipulation of a bag when nuclear removal has already been completed safely.

Disadvantages

• The unstable bag receives no support during phacoemulsification.
• Not suitable when zonular weakness is substantial from the beginning.

Practical rule

• Mild weakness: insert late, after nucleus removal or after cortical cleanup.
• Moderate instability: insert after nucleus removal but before difficult cortical aspiration.
• Marked instability: use capsular hooks/CTS for early support and consider a Cionni ring or scleral fixation.

Surgical Technique for Standard CTR Insertion

Preparation

1. Make a well-centered, adequately sized continuous curvilinear capsulorhexis.
2. Perform careful hydrodissection and hydrodelineation.
3. Fill the capsular bag with cohesive OVD to expand and protect it.
4. Identify the area of zonular weakness or dialysis.

Insertion methods

A. Manual insertion

• Grasp the leading eyelet with forceps.
• Introduce the leading end into the capsular bag.
• Advance and dial the ring gently along the capsular equator.
• Keep the leading end away from the area of dialysis when possible.
• Ensure that both ends lie completely within the capsular bag.

B. Injector-assisted insertion

• Load the CTR into a dedicated injector.
• Deliver it smoothly into the capsular bag under OVD.
• Control the leading end carefully to prevent it from catching the capsulorhexis edge or tearing the posterior capsule.

Important technical points

• Maintain the capsular bag inflated with OVD.
• Avoid forceful dialing.
• Avoid engaging the posterior capsule with the leading eyelet.
• A capsular hook may guide the leading end in eyes with a weak or absent zonular sector.
• Reassess bag centration after ring placement.
• Remove trapped cortex carefully before IOL insertion.

Use of Capsular Hooks

• Zonular loss is significant
• The bag is severely decentered
• A Cionni ring is planned
• Early bag stabilization is needed during capsulorhexis and nucleus removal

IOL Implantation After CTR

Preferred IOL placement

• In-the-bag posterior chamber IOL
• Ensure centration of the IOL and capsular bag complex
• Use a suitable IOL design according to the individual eye and surgical plan

In severe zonular loss

• Cionni ring with scleral fixation
• Capsular tension segment with scleral fixation
• Alternative IOL fixation methods
• Staged surgery if the capsular bag cannot be preserved safely

Complications of CTR Use

Intraoperative complications

• Extension of zonular dialysis
• Increased lens or bag subluxation during insertion
• Capsulorhexis tear
• Posterior capsule rupture
• Entrapment of cortex between ring and capsule
• Difficulty in cortical aspiration
• Inadvertent insertion of the CTR into the ciliary sulcus rather than the bag
• Dislocation of the CTR into the vitreous, especially if there is an unrecognized posterior capsular defect
• Failure to achieve adequate centration in severe zonulopathy

Postoperative complications

• IOL or bag-CTR complex decentration
• Late in-the-bag IOL-CTR complex dislocation, especially in progressive pseudoexfoliation-related zonulopathy
• Capsular phimosis/contraction
• Posterior capsular opacification
• Raised IOP
• Uveitis
• Cystoid macular oedema
• Retinal detachment, particularly in complex eyes with severe zonular disease

Advantages

• Preserves the capsular bag
• Allows in-the-bag PCIOL implantation in many complex cases
• Improves bag stability during surgery
• Improves IOL centration
• Reduces risk of further zonular damage in selected cases
• Helps distribute forces over the remaining intact zonules
• Can make cataract surgery safer in mild to moderate zonular weakness

Limitations

• Does not replace absent zonules
• Cannot provide sufficient support in extensive zonular loss without scleral fixation
• May trap cortex and complicate aspiration
• Can worsen dialysis if inserted forcefully
• May not prevent delayed dislocation in progressive disorders
• Requires correct case selection and surgical expertise

Exam Summary