Answering key questions on surgical technique and postoperative management in complex cataract surgery
In complex cataract cases, the surgical plan must be adapted to the anatomy, underlying pathology and likely postoperative risks. Eyes with previous corneal transplantation, high myopia, ocular trauma or irregular corneal disease may require modified techniques, careful intraoperative judgement and closer follow-up after surgery.
This second article in this two-part FAQ series, based on our Expert Pearls series, summarises expert guidance on surgical decision-making, complication avoidance and postoperative management, including when to consider, delay or avoid Nd capsulotomy for posterior capsule opacification.
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How can the graft be protected during cataract surgery after penetrating keratoplasty?
The surgical plan should minimise trauma to the graft–host junction and the endothelium. Incision placement should be chosen carefully, and a limbal or scleral approach may be preferable if the graft is large, the host rim is narrow or the peripheral cornea is thinned.
Endothelial protection is central. A soft-shell technique using dispersive and cohesive ophthalmic viscosurgical devices is used to protect the graft endothelium. Phaco energy and fluidic turbulence should be minimised, and the surgeon should avoid bringing nuclear fragments close to the cornea.
→ Read the full article: Expert pearls in cataract surgery after penetrating keratoplasty
What principles guide surgery in traumatic cataract cases?
Visibility is non-negotiable. The surgeon should have a clear view of the relevant structures before proceeding. A useful sequence is diagnosis, surgical planning and then execution, with readiness to adapt according to how the tissues behave during surgery.
Associated injuries should guide the technique. Hyphaema may need irrigation before deeper structures can be assessed. Vitreous prolapse should be identified using triamcinolone, and if vitreous is present or its absence cannot be confirmed, a vitrector rather than a phaco probe may be safer.
In traumatised eyes, the goal is not simply to place an IOL in the capsular bag, but to restore the eye as safely as possible.
→ Read the full article: Expert pearls on traumatic cataract management
What surgical considerations are important in high myopia?
Altered anatomy can make cataract surgery more challenging in highly myopic eyes. Zonular weakness and an enlarged capsular bag may compromise capsular stability and increase the risk of IOL decentration or dislocation. Tissues should therefore be handled gently, with capsular tension rings considered in selected cases.
Posterior capsule rupture is particularly concerning because vitreous in the anterior chamber can increase vitreoretinal traction and the risk of retinal detachment. If rupture occurs, thorough anterior vitrectomy is essential.
Meticulous cortical clean-up and capsule polishing are also important because younger patients with high myopia may develop posterior capsule opacification more rapidly.
→ Read the full article: Cataract surgery in patients with high myopia
When should surgeons modify the original surgical plan?
Complex cataract surgery requires a flexible, case-specific plan. The surgeon should enter the case with a preferred approach but remain prepared to change strategy if visibility is inadequate, tissues behave unexpectedly or ocular structures cannot be managed safely.
This is especially important in traumatic cataract, previous penetrating keratoplasty and highly myopic eyes, where the safest decision may be to modify the technique, use condition-specific support measures, stage the procedure or prioritise ocular stability over the original refractive plan.
Support devices should be selected cautiously. For example, capsular tension rings may be considered in selected highly myopic eyes but are generally discouraged in traumatised eyes when the extent of zonular damage is uncertain.
→ Read the full articles:
- Expert pearls on traumatic cataract management
- Expert pearls in cataract surgery after penetrating keratoplasty
- Expert pearls: Cataract surgery in patients with high myopia
How can surgeons reduce the risk or severity of posterior capsule opacification during cataract surgery?
Reducing posterior capsule opacification starts at the time of cataract surgery. Meticulous cortical clean-up, safe removal of residual lens epithelial cells, complete removal of ophthalmic viscosurgical device and a well-centred capsulorhexis with full 360-degree optic overlap can all help reduce clinically significant PCO.
A continuous sharp posterior square-edge IOL design also creates a mechanical barrier to lens epithelial cell migration.
The underlying principle is to reduce both the viable cells and the space available for their migration.
→ Read the full article: Expert pearls in posterior capsule opacification after cataract surgery
When should Nd laser capsulotomy be considered for posterior capsule opacification?
Nd laser capsulotomy should be considered when posterior capsule opacification is clearly responsible for the patient’s visual symptoms.
After uncomplicated cataract surgery, treatment is often delayed until around 3 months, although earlier intervention may be appropriate for dense fibrotic PCO, significant capsular contraction or visually disabling PCO after refractive cataract surgery.
Treatment should usually be delayed in patients with active inflammation, recent cystoid macular oedema, unstable retinal disease or recent symptomatic posterior vitreous detachment.
→ Read the full article: Expert pearls in posterior capsule opacification after cataract surgery
When should Nd laser capsulotomy be avoided?
Nd laser capsulotomy should be avoided when there is a realistic chance that the patient may need IOL rotation or IOL exchange. Preserving an intact posterior capsule makes secondary IOL surgery easier and safer.
It is also important not to assume that every patient with reduced vision and capsular wrinkling has clinically significant PCO. IOL opacification and late capsular bag distension syndrome are important PCO masqueraders, and anterior segment OCT may help localise the opacity in selected cases.
Persistent low-grade inflammation associated with a capsular plaque should also prompt consideration of chronic Cutibacterium acnes endophthalmitis before the posterior capsule is opened.
→ Read the full article: Expert pearls in posterior capsule opacification after cataract surgery
What postoperative counselling is important after complex cataract surgery?
Postoperative counselling should reflect the preoperative risk profile. Patients with high myopia may need continued retinal monitoring and should be advised to seek urgent assessment if they develop flashes, new floaters or a visual-field defect.
Patients with previous penetrating keratoplasty require close observation for graft oedema, inflammation, rejection, endothelial failure and postoperative or steroid-related IOP elevation.
In traumatic cataract cases, visual recovery may depend on associated ocular injuries, and close, extended follow-up is important because complications may appear several weeks after treatment.
In keratoconus or other irregular corneal conditions, patients may still need spectacles, contact lenses or further refractive management after surgery. Clear counselling helps avoid disappointment when surgery improves vision but does not fully normalise visual quality.
→ Read the full articles:
- Expert pearls on traumatic cataract management
- Expert pearls in cataract surgery after penetrating keratoplasty
- Expert pearls: Cataract surgery in patients with high myopia
- Expert pearls: Optimising cataract surgery in keratoconus
Key takeaway
In complex cataract surgery, success depends on adapting the technique to the individual risk profile. Protecting vulnerable structures, recognising when to modify the surgical plan and managing postoperative complications carefully can help improve outcomes in eyes where routine approaches may not be sufficient.
→ Don’t forget to read part one: Decision-making in preoperative planning and IOL selection
Cite: Cataract surgery FAQs: Surgical technique and postoperative management. touchOPHTHALMOLOGY. July 15, 2026.
Disclosure: This article was created by the touchOPHTHALMOLOGY team utilizing AI as an editorial tool (Claude [Sonnet 5]. https://claude.ai.) The content was developed and edited by human editors. No funding was received in the publication of this article. Thank you to the authors who shared their practice pearls within our Expert Pearls series.
Editor: Nicola Cartridge, Director of Content
