Eyeworld

FALL 2026 | EYEWORLD | 49 C About the physicians Amar Alwitry, MD Woodthorpe Hospital Nottingham, U.K. Jennifer Lindsey, MD Diane and Albert Kaneb Chair in Ophthalmology Massachusetts Eye and Ear Residency Program Director and Vice Chair for Education in Ophthalmology Harvard Medical School Boston, Massachusetts by Ellen Stodola Editorial Co-Director I n cataract surgery, surgeons should always be prepared for potential challenges or complications, but some complications and side effects are more common and well documented than others. In this article, two physicians discussed an uncommon cataract complication that they think is important to call attention to and what other ophthalmologists should know when dealing with these. Rupture of the posterior capsule Jennifer Lindsey, MD, said that rupture of the posterior capsule due to retained cavitation bub- bles after laser nucleus fragmentation in femto- second laser-assisted cataract surgery (FLACS) is important to be aware of, and not forget about, particularly for surgeons who are new to the technology or who use it infrequently. "This happens when cavitation (gas) bubbles, pro- duced during lens fragmentation, get trapped behind the lens and can cause an abrupt rupture or 'blowout' of the posterior capsule during hy- drodissection or phacoemulsification," she said. The good news is this a rare complication, occurring in less than 1% of cases. However, Dr. Lindsey said that it can be concerning because of the nature of FLACS surgery; these patients may be paying additional out-of-pocket costs and have high expectations for their surgical outcomes. "A posterior capsular tear may limit the available intraocular lens choices," such as toric or multifocal, she added, and can result in additional surgical time and increased incidence of postoperative inflammation, cystoid macular edema, or retained lens fragments. Dr. Lindsey noted that surgeons are taught about this potential complication when learning to use the femtosecond laser. The best way to prepare for it is to remember that it can happen and take steps to prevent it. "It is best to release the cavitation bubbles prior to hydrodissection, for example, by using a prechopper or nucleus cracker to separate the fragmented pieces of the nucleus to allow the bubbles to rise up from behind the lens," she said, adding that hydro- dissection in FLACS cases should be performed gently and carefully. Dr. Lindsey said the surgeon should watch out for signs of posterior capsular rupture, such as a sudden deepening of the anterior cham- ber or instability of the lens material during phacoemulsification. If the posterior capsule is torn, she said the surgeon should treat this like any other posteri- or rupture: • Avoid rapid changes in anterior chamber pressure; • Use copious dispersive viscoelastic to tamponade the anterior vitreous; • Remove only the lens material that you can access safely without putting traction on the vitreous. If there is vitreous prolapse, Dr. Lindsey suggested performing careful anterior vitrecto- my and trying to put a lens in the ciliary sulcus if there is adequate remaining capsular support. "Optic capture in the intact anterior rhexis is ideal if it can be done safely," she said, adding that you may want to refer the patient to a reti- na colleague for further management if there is any lens material that falls posteriorly into the vitreous. Dr. Lindsey stressed that careful planning and attention to detail can help avoid this complication. "It is easy for a surgeon to get into a routine of performing hydrodissection immediately after the capsulorhexis," she said. "Keep in mind that things are a little different Uncommon cataract complications to be aware of continued on page 50 " Keep in mind that things are a little different with FLACS, and it is best to take some time to release the cavitation bubbles prior to hydrodissection." —Jennifer Lindsey, MD

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