## Most Common Intraoperative Complication in Cataract Surgery **Key Point:** Posterior capsule rupture (PCR) is the most common intraoperative complication of phacoemulsification, occurring in 1–3% of routine cases and up to 10–15% in complicated cases. ### Incidence and Risk Factors | Complication | Incidence | Risk Factors | |---|---|---| | Posterior capsule rupture | 1–3% (routine), 10–15% (complex) | Mature cataract, zonular weakness, posterior synechiae, small pupil, brunescent nucleus | | Corneal endothelial cell loss | Occurs with all cases (5–10% loss) | Prolonged phaco time, high ultrasound energy, older age | | Iris prolapse | < 1% | Inadequate mydriasis, positive vitreous pressure | | Zonular dehiscence | < 1% | Pseudoexfoliation, Marfan syndrome, trauma history | **High-Yield:** PCR is the single most frequent intraoperative adverse event in routine cataract surgery. It is managed by converting to extracapsular extraction or in-the-bag IOL placement with careful anterior vitrectomy if vitreous prolapse occurs. ### Mechanism of PCR 1. Hydrodissection and hydrodelineation create fluid pressure against the capsule 2. Phacoemulsification energy transmitted to nucleus can stress weakened posterior capsule 3. Zonular dehiscence or capsular weakness (age, pseudoexfoliation) predisposes to rupture 4. Positive vitreous pressure from Valsalva or inadequate anesthesia increases risk **Clinical Pearl:** Even with PCR, modern surgical technique allows safe IOL placement in most cases. Anterior vitrectomy and careful IOL positioning in the ciliary sulcus or bag (if capsule intact) yield good visual outcomes. **Warning:** Corneal endothelial cell loss is a *universal* consequence of phacoemulsification (not an "event" but a physiologic cost), so it is not classified as a discrete intraoperative complication in the same sense as PCR or iris prolapse.
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