Capsular rents are not all created equal. They come in varying severity, require somewhat different approaches, and may cause different degrees of consequences. So, I will deal with them in order of complexity and then conclude with a general plan for OVD choice and use that applies to all cases. The different types of capsular rents are as follows:

The simplest case to consider is that where the nucleus has been removed, some cortex remains, and a small round, punched hole is noted in the posterior capsule, with or without vitreous protruding.

The first thing to do is to leave the phaco or I/A in the eye, in position 1, irrigation only, and observe, as the bottle height is lowered gradually to keep things stable. No matter how round the hole looks, do not assume it to be perfectly round and therefore unlikely to split radially. Notice if vitreous appears to be in the anterior chamber or not (before even considering injecting triamcinolone), aided by observing if the hole is pulled to one side, indicating that vitreous has emerged from it and is now caught somewhere (incision, side port, residual nuclear or cortical fragments, phaco tip). While holding the handpiece in position 1 with the bottle lowered to just maintain stability of the AC, inject a dispersive OVD (my own preference is VISCOAT®) through the side port with your other hand, initially remote from the hole, stabilizing the perimeter of the anterior chamber, and gradually injecting concentrically inward to encircle the hole and any possible protruding vitreous. As this step progresses, slowly remove the phaco or I/A once the OVD has adequately pressurized the AC to keep it from collapsing (which would encourage vitreous to come forward). Once the phaco or I/A is out, a stable, quiet anterior chamber with a round hole in the OVD-supported posterior capsule remains. Next, it is necessary to assure that the posterior capsule is in a balanced supported environment between the OVD-filled AC and the posterior segment. However, the posterior segment, which at this point is uncertainly filled with either OVD or vitreous immediately behind the posterior capsular rent, may also have some vitreous protruding through the hole. To ascertain the status, triamcinolone could be injected now, but it is better to wait. Instead, continue to inject dispersive OVD until the posterior capsule is flat and completely unstressed. The circumferential injection of the dispersive OVD has assured that any protruding vitreous has been slowly moved centrally back over the hole; so, more dispersive OVD should be gently injected through the capsular opening, which, if the preceding injection has been done carefully, should push the bulging vitreous back through the hole and leave it behind the posterior capsule. A posterior capsulorhexis is now gently done with microforceps. This is probably the most difficult step, as judgment tells the surgeon when is the best time to perform the PCC, and good judgment only comes from past experience. Nevertheless, once the PCC is completed, a viscous cohesive OVD (I prefer Healon GV® or Healon5®) is gently injected into the center of the AC, which pushes the dispersive OVD overlying the hole and any remaining vitreous strands back through the hole behind the posterior capsule, and causes the now-strong posterior capsule to bow slightly posteriorly. I prefer a viscous cohesive OVD here because it establishes a clear boundary between itself and the dispersive. The dispersive may still have some strands of vitreous enmeshed with it, but a cohesive OVD will push all this away, and leave the center of the AC, above the hole, with cohesive OVD only, and no vitreous, which could become entangled in the incoming IOL later on in the procedure. Injection of the cohesive OVD is done cautiously, as it is important not to increase the pressure in front of the capsular tear significantly higher than the pressure behind it; so, observation of the posterior capsule determines when to stop the injection. Residual cortex is then aspirated using the dry technique (first popularized by Aziz Anis [2] aspirating cortex with a syringe containing a small amount of BSS, to eliminate air, but no irrigation, refilling the perimeter of the capsular bag with more dispersive OVD, as needed). Once the cortex has been removed, the capsular bag is refilled with viscous cohesive OVD, reestablishing a reasonably deep, anterior chamber and capsular bag, being careful not to over pressurize the AC, and further pushing the dispersive OVD and vitreous behind the posterior capsulorhexis. The preselected IOL is then injected into the vitreous-free capsular bag and gently positioned. It is desirable, if the posterior capsulorhexis is central and round, as it should be after the PCCC to capture the IOL optic in the posterior capsulorhexis, as this step prevents any further anterior movement of vitreous. There is no need to remove any OVD from behind the captured IOL, as it does not have ready access to the angle. This point is very important to remember. If the posterior capsule is inadequate for IOL capture, a sulcus-placed three-piece IOL should be used, and the IOL optic captured in the anterior capsulorhexis. The anterior capsulorhexis should always be done extremely carefully in cataract surgery, and should always be well centered and never be more than 5 mm in diameter if the planned IOL diameter is 6 mm. It remains a safety valve to capture the IOL if any problem with the posterior capsule occurs in surgery. If the perimeter of the capsulorhexis is allowed to exceed that of the IOL optic, successful capture of the IOL and the ensuing separation of the anterior and posterior segments of the eye with a stable barrier cannot be achieved. The advantage of a stable AC/vitreous barrier should never be sacrificed, and wherever possible, as outlined above, protruding vitreous should be put back and not removed.