Cataract surgery in eyes that have had trabeculectomy poses a threat to the functioning bleb because of the risk of inflammation and scarring [14, 15]. Vitreous loss further increases the chances of failure due to the blockade of the stoma.

Use of prostaglandin analogs in patients who have had a posterior capsular rent is reported to cause cystoid macular edema (1.5–2 %) [16, 17]. Hence, it is preferable to avoid using prostaglandin analogs in high-risk eyes.

Appropriate preoperative management is vital as it helps in early rehabilitation and reduces the chances of early and late postoperative complications. Management protocol is more or less similar for all patients, which would include early recognition, maneuvers to prevent nucleus drop, minimizing and managing vitreous loss, and placement of an appropriate stable intraocular lens. Management also depends upon the stage of the surgery.

If PCR occurs before the nucleus removal, management of the nucleus/nuclear fragment is the most important aspect. The main goal would be to prevent the dislocation of the nucleus fragment into the vitreous cavity. Once the posterior capsular rupture is recognized, do not withdraw the probe from the eye immediately, as this movement can cause extension of the tear and prolapse of vitreous (Fig. 18.3). A dispersive viscoelastic must be injected beneath the lens material to tamponade the vitreous, sequester lens fragments anteriorly, and further protect the capsule during nucleus retrieval [18]. Dispersive viscoelastics resist being aspirated, assist delineation of nucleus fragments, and tamponade the vitreous. The advantage of the dispersive agents is that they are more easily filtered out through the trabecular meshwork and prevent IOP spike. In patients with glaucoma, the viscoelastic must be removed to the extent possible.

Residual nuclear matter may be removed either by emulsification or by converting to an extracapsular technique. If most of the nucleus has already been emulsified, the surgeon may use a second instrument to push the nuclear fragment away from tear into the anterior chamber and to complete phacoemulsification. Short bursts of low-energy ultrasound with low aspiration and reduced irrigation will decrease the risk of nuclear loss, chamber shallowing, and vitreous prolapse. After the emulsification of the nucleus, the phacoemulsification handpiece must be removed, while viscoelastic is simultaneously injected through the side port. Viscoelastic or lens glide [19] can be used to stabilize leftover nuclear fragments in the anterior chamber before removal. Whenever manual retrieval of the nuclear fragment is required, the incision should be enlarged, and if the nucleus is still in one piece, it may be possible to prolapse the nucleus out of the bag by viscodissection.

Cortical aspiration may be safely accomplished without extension of the tear by following several maneuvers. “Low-flow” irrigation minimizes the chances of vitreous prolapse through the tear. The cortex away from the tear must be removed initially, leaving the cortex at the vicinity of the tear for the last. The cortex should be stripped toward the rent, as the forces generated away from it will cause its extension. The withdrawal of the irrigation-aspiration handpiece must be accompanied by injection of viscoelastic/air into the anterior chamber to maintain the chamber depth. An alternative safer approach would be to manually remove the cortex using a straight or bent cannula under the protection of the viscoelastic.

Posterior capsular rupture is a complication, which can occur at virtually any stage of the surgery. The 5-year audit results on phacoemulsification surgery and posterior capsular rupture done at the Singapore National Eye Centre [27] reported that visual outcome was significantly worse in those eyes with PCR than in cases with intact capsule, and the stage at which the rupture occurred did not affect the outcome. The risk factors associated with poor visual outcome were age >65 years, nucleus drop, or other postoperative complications. In a study done by Ang et al. [28], the most common complication needing intervention, following a posterior capsular tear, was raised intraocular pressure requiring additional medications. Around 20 % had raised IOP on the first postoperative day, but in all of them IOP returned to normal with appropriate medical management. The factors that contribute to this include retained viscoelastics, residual lens matter, and increase in inflammatory mediators. This spike in intraocular pressure in the early postoperative is more frequent in eyes with glaucoma [29]. Use of prophylactic IOP lowering treatment should be considered in patients at high risk [30]. In a study done by Byrd et al. [31], using preoperative oral acetazolamide 500 mg 1 h before surgery helped control early postoperative IOP elevation. Postoperative IOP elevation can be controlled medically using oral acetazolamide, topical β-blockers, carbonic anhydrase inhibitors, and α-2 agonists. It is preferable to avoid prostaglandins analogs due to the risk of development of inflammation and cystoid macular edema. There is also a controversy regarding use of aqueous suppressants in the early postoperative period, as they delay washout of retained viscoelastics [31]. Anterior chamber decompression by using a 30-gauge needle through the side-port incision is another quick and effective method of lowering IOP [32].