Complete Anterior Capsule Explosion" During Phacoemulsification: Peripheral-To-Central Tear Propagation With Successful Ma60ac 3-Piece Iol Bag Placement And 10/10 Visual Outcome

To report an extremely rare intraoperative complication during phacoemulsification: complete anterior capsule "explosion" with peripheral-to-central tear propagation (reverse of typical central-to-peripheral CCC extension), leaving posterior capsule completely intact. This case demonstrates original stabilization maneuvers permitting successful 3-piece MA60AC IOL implantation directly into capsular bag despite total anterior capsule loss, avoiding sulcus placement complications. Highlights atypical capsule tear biomechanics, innovative intraoperative management, and excellent 2-month outcome (10/10 with +0.25-1.25×96), providing technique for surgeons facing this 0.1-0.2% incidence catastrophe

73-year-old female with dense cataract at Hospital Lagleyze (university teaching hospital), Buenos Aires, Argentina. Performed by surgeon-in-training accompanied by experienced instructor. Standard 2.4 mm clear corneal incision, chop technique. Available IOL: Alcon MA60AC 3-piece hydrophobic acrylic (24 D). Postoperative follow-up: 1 week, 1 month, 2 months. Video documentation available detailing stabilization maneuvers, capsule explosion discovery, and IOL placement

PREOPERATIVE ASSESSMENT
73-year-old female presented with dense nuclear cataract OU and poor uncorrected distance visual acuity (UDVA <0.1 decimal). Slit-lamp examination revealed healthy cornea, no pseudoexfoliation, normal anterior chamber. Biometry targeted emmetropia (24 D IOL power).Clear corneal incision 2.4mm and hydrodissection uneventful. Continuous curvilinear capsulorhexis initiated without resistance. During nuclear disassembly, sudden capsulorhexis eccentricitation observed—initially interpreted as zonular dialysis by training surgeon.

ORIGINAL STABILIZATION MANEUVERS (instructor-guided):

• Abundant viscoadaptive OVD injection supporting capsular equator

• Iris retractors stabilizing fornix (preventing vitreous prolapse)

• Capsule forceps repositioning equatorial rim

• Dispersive OVD maintaining anterior chamber

CRITICAL DISCOVERY (cortical cleanup): Complete anterior capsule "explosion"—peripheral tear propagated centrally, ejecting entire anterior capsule membrane while posterior capsule remained INTACT. MA60AC 24 D 3-piece IOL selected. Lead haptic inserted perpendicular to equatorial tear sector. Optic rotated 90°; trailing haptic positioned opposite. Perfect centering confirmed under OVD.viscoelastic aspiration.

POSTOPERATIVE OUTCOMES
Day 1: UDVA 0.6 decimal, well-centered IOL, mild cell/flare.
1 month: UDVA 0.7 plano, stable position.
2 months: UDVA 10/10 (+0.25-1.25×96), UNVA J3, quiet anterior chamber. Slit-lamp confirmed stable bag placement without tilt/pseudophakodonesis

Key lessons:

1. Atypical peripheral→central tear propagation in rigid dense cataracts

2. Original stabilization: Iris retractors+ experience manuvers  + viscoadaptive OVD + capsule forceps prevent posterior extension (24-48% risk)

3. MA60AC 3-piece BAG placement optimal: Haptics perpendicular to tear ensure stability without CCC

4. Training value: Experienced instructor (>3000 cases) + real-time guidance = 10/10 resultdespite complete capsule loss

Rare complications continue teaching. Expert supervision converts intraoperative disasters into publishable successes. Video documents unique technique. 3-piece bag IOL preferredover sulcus when posterior capsule intact (avoids 15-20% decentration risk)