During phacoemulsification in an otherwise routine cataract surgery, the surgeon notices sudden deepening of the anterior chamber, momentary pupil snap, and a fragment of lens cortex falling posteriorly. On inspection, there is a posterior capsule rupture with vitreous visible in the anterior chamber. Which of the following is the most appropriate immediate next step?
A. Carefully continue phacoemulsification to clear the remaining cortical fragments before addressing the rupture
B. Inject viscoelastic posterior to the capsular defect to tamponade the vitreous before further maneuvers
C. Immediately convert to extracapsular cataract extraction (ECCE) without further intervention
D. Perform anterior vitrectomy using the phacoemulsification handpiece’s standard irrigation/aspiration settings
E. Perform a limbal-based anterior vitrectomy using high infusion flow and low cut rate
Answer: B
The first priority once a posterior capsule rupture with vitreous prolapse is recognized is to stop phacoemulsification and stabilize the eye. Injecting viscoelastic behind/under the capsular defect tamponades the vitreous, protects the posterior segment, and prevents further prolapse while the surgeon plans next steps (anterior vitrectomy, decision on sulcus vs. scleral-fixated IOL, etc.).
A. Continuing phaco with retained vitreous in the AC risks vitreous traction on the peripheral retina, dramatically raising the risk of retinal tears or detachment — one of the most dangerous consequences in this scenario.
C. Converting to ECCE is not always required, many ruptures are manageable with visco stabilization and anterior vitrectomy alone.
D. The standard phaco irrigation/aspiration sleeve is designed for cortical cleanup, not vitrectomy, using it at this point in time would cause more turbulence and vitreous traction rather than clean removal.
E. Proper anterior vitrectomy technique uses low infusion flow and a high cut rate (to minimize traction), the opposite of what’s listed here.