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Journal of Clinical & Translational Ophthalmology
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30 November 2025

Incidence and Outcomes of Dropped Nucleus After Phacoemulsification Cataract Surgery Between 2020 and 2024

,
,
,
and
Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, UK
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Author to whom correspondence should be addressed.
J. Clin. Transl. Ophthalmol.2025, 3(4), 26;https://doi.org/10.3390/jcto3040026 
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Abstract

Background: This study evaluates the incidence and outcomes of patients with dropped nucleus/nuclear fragment during phacoemulsification surgery; Methods: Retrospective review of continuous cases with dropped nucleus/nuclear fragment during phacoemulsification cataract surgery from January 2020 to December 2024. Demographic and perioperative data were collected and analysed. A good visual outcome was defined as a postoperative best-distance visual acuity of ≥6/12; Results: A total of 91,883 cases of planned phacoemulsification cataract surgery were identified, of which 175 (0.19%) were complicated by a dropped nucleus/lens fragment. Mean age was 71 years and median number of days from primary procedure to secondary fragmatome was 5 days. Good visual outcomes were achieved in 127 cases (73%). Median final intraocular pressure was 13 mmHg. Most patients required two (63%) or three (29%) operations in total and none developed endophthalmitis. Hypermature cataracts were present in 70 cases (40%) and were significantly associated with poor visual outcomes (p = 0.003). Surgeon grade and other pre-existing ocular co-pathologies known to increase posterior capsular rupture risk were not significantly associated with poor visual outcomes; Conclusions: Overall incidence and outcomes of cases complicated with dropped nucleus/fragment were favourable despite the presence of pre-existing risk factors. Emergent management is paramount to ensure good outcomes in patients.

1. Introduction

Cataract surgery is the most common operation in the world, responsible for restoring sight to individuals with visual impairment and blindness []. It is also the most common surgery performed on the National Health Service (NHS) in the United Kingdom (UK) []. The posterior displacement of crystalline lens fragments or the entire crystalline lens into the vitreous cavity is referred to as “dropped nucleus”.
It is estimated to occur at a rate between 0.1 and 1.8% [,,,]. The variation in incidence reflects differences in study populations and reporting methodologies. Studies involving large-scale registry data provide some of the lowest estimates, with the European Registry of Quality for Cataract Outcomes (EUREQO) reporting an incidence of approximately 0.071% and a 16-year study from a major tertiary centre in Singapore reporting an incidence of 0.17% [,]. However, the majority of the studies were case series reporting a broader range of figures [,,,,,]. This variability demonstrates that while the complication is uncommon, it remains a well-recognised challenge during phacoemulsification cataract surgery.
Phacoemulsification cataract surgery complicated by posterior capsular rupture is associated with a dropped nucleus, accounting for over 90% of cases, with the remaining cases caused by zonular dehiscence [,]. The risk factors for posterior capsular rupture were well-described in a study by Narendran et al. in 2009 []. An older age, male gender, glaucoma, diabetic retinopathy, hypermature cataract, no fundal view, pseudoexfoliation (PXF), phacodonesis, smaller pupils, longer axial length, intraoperative floppy iris syndrome-inducing alpha receptor blocker use, inability to lie flat, or a junior surgeon grade were associated with a higher risk of PCR []. Similarly, the risk factors for zonular dehiscence comprised older age, glaucoma, hypermature cataracts, PXF, extremes of axial lengths, smaller pupils, eyes with previous vitrectomy, and a junior surgeon grade []. These risk factors overlap those of a dropped nucleus, although it is not fully clear how they affect the visual outcomes of patients with a dropped nucleus due to a paucity of data.
The association of dropped nucleus with sequelae such as intraocular inflammation, glaucoma, corneal oedema and cystoid macular oedema (CMO), and retinal detachment (RD) is well described in the literature [,,]. Prolapsed nuclear lens material into the vitreous cavity can precipitate phacoantigenic ocular inflammation, which can lead to further endothelial damage, trabecular meshwork and retinal dysfunction []. Effective intraoperative and postoperative management is required to reduce the risk of associated further complications. The management of a dropped nucleus represents a complex challenge. It typically involves a multi-stage approach involving both the cataract anterior segment surgeon and a vitreoretinal surgeon. An excellent visual prognosis is dependent on experienced emergent management of the initial complication and the timely handling of subsequent secondary pars plana vitrectomy (PPV) and fragmatome procedure.
This study evaluates the incidence and outcomes of patients with dropped nucleus after phacoemulsification surgery, which would contextualise the complication rate in its real-life clinical setting and contribute to the evidence base surrounding this complication.

2. Methods

2.1. Study Design

A retrospective cohort study of cases with dropped nucleus after phacoemulsification cataract surgery from 1 January 2020 to 31 December 2024 at Moorfields Eye Hospital NHS Foundation Trust was undertaken. Electronic medical records (EMRs) were reviewed to identify eligible cases. Demographic and perioperative data were extracted and anonymised. The Declaration of Helsinki and UK NHS Health Research Authority guidance on ethical approval were adhered to.

2.2. Inclusion and Exclusion Criteria

The inclusion criteria were cases that comprised a phacoemulsification procedure and subsequent PPV +/− fragmatome within 30 days. The exclusion criteria were cases that underwent a planned PPV and fragmatome as a primary procedure.

2.3. Demographics and Clinical Characteristics

Demographic data collected comprised age at surgery, sex, operated eye sequence and laterality. Perioperative data collected comprised best distance visual acuity (BDVA), intraocular pressure (IOP), patient co-pathologies including posterior capsular rupture (PCR) risk factors such as the ability to lie flat, axial length (AL) ≥ 26 mm, brunescent/white (hypermature) cataract, diabetes mellitus, alpha receptor blocker use, glaucoma, no fundal view, small pupil size, pseudoexfoliation syndrome (PXF) and/or phacodonesis, surgeon grade, post-traumatic cataract, dementia with surgery performed under local anaesthesia (LA), previous intravitreal injections, and previous PPV.

2.4. Study Outcomes

The primary outcome was a favourable visual outcome defined as a postoperative BDVA of ≥6/12. Cases were categorised into eyes that had a favourable visual outcome (BDVA ≥ 6/12) and eyes that did not have a favourable visual outcome (BDVA < 6/12). BDVA was measured as the best visual acuity reading on the Snellen chart at the final follow-up appointment with or without refractive correction, including using a pinhole visual acuity.

2.5. Statistical Analysis

Anonymised data was coded on a database created on Microsoft Excel spreadsheets (Microsoft Corporation, Redmond, WA, USA), which was imported into SPSS Statistics Version 29 (IBM Corporation, Endicott, NY, USA) for statistical analyses. Continuous data were first examined for normality using the Shapiro–Wilk test, with statistically significant values deemed as deviating from a normal distribution. Data that were found to be normally and not normally distributed were expressed as mean (range) and median (range), respectively. Differences in demographic and clinical characteristics were compared between two groups defined by the visual outcome: a good visual outcome of BDVA ≥ 6/12 and a poor visual outcome of BDVA < 6/12. Statistical analysis on categorical data was performed using Fisher’s exact tests for factors with binomial categories and X2 tests for factors with >2 categories. Continuous data were analysed using the independent samples t-Test if they were normally distributed and Mann–Whitney U Test if they were not normally distributed. A statistically significant level was set at a p value of <0.05.

3. Results

3.1. Baseline Demographics

A total of 91,883 phacoemulsification cataract cases were identified between 2020 and 2024, of which 175 (0.19%) had dropped nuclei. A good visual outcome of BDVA ≥ 6/12 was achieved in 127 cases (73%). The mean age at surgery was 71 years (range 45–94 years). There were 76 female patients (43%) and 99 male patients (57%) with dropped nuclei. In 92 cases the eyes involved were left eyes (53%) and in 83 cases were right eyes (47%). The majority of cases involved the first operated eye (n = 132) (75%). There were no statistically significant differences in the demographic data between the group with good visual outcomes and the group with poor visual outcomes (Table 1).
Table 1. Baseline demographic characteristics.

3.2. Co-Pathologies and PCR Risk Factors

Most patients were able to lie flat, with all but four not being able to do so (2.3%) and only one case (0.6%) involved surgery performed under local anaesthesia in a patient with dementia. A total of 88 cases (50%) were patients with type 2 diabetes mellitus. Previous or current use of alpha receptor blockers was found in 20 patients (12%). Glaucoma was present in 21 cases (12%). A total of 10 patients (6%) had previous intravitreal injections to treat and 10 patients (6%) had undergone previous PPV.
A long axial length of ≥26 mm was found in 18 cases (10%). Hypermature cataracts were present in 70 cases (40%) and 46 had no fundal view (26%). Small and medium pupils were found in 15 (9%) and 30 (17%) cases, respectively. Pseudoexfoliation and/or phacodonesis were found in 21 cases (12%) and previous ocular trauma was present in two patients (1.1%). A total of 113 cases (65%) involved a non-consultant surgeon, comprising residents and fellows, while 62 cases (35%) involved a consultant surgeon. Surgeon grade and pre-existing ocular co-pathologies known to increase the PCR risk score were not significantly associated with poor visual outcomes, apart from a hypermature cataract (p = 0.003) (Table 2).
Table 2. Identified co-pathologies and posterior capsular rupture risk factors.

3.3. Postoperative Factors Affecting Visual Outcome

The median number of days from initial phacoemulsification procedure to PPV +/− fragmatome was 5 days (range 0–27 days), 115 patients (66%) had a secondary procedure within 7 days, and 160 patients (91%) within 14 days. There were 51 cases (29%) that involved the prolapse of the entire lens nucleus into the vitreous cavity. In four cases (2.3%) only one operation was needed as there was a vitreoretinal surgeon available to perform immediate sequential PPV +/− fragmatome with no other secondary procedures performed subsequently. Most patients required two (n = 111) (63%) or three (n = 51) (29%) operations in total, comprising the primary phacoemulsification procedure and a second subsequent PPV +/− fragmatome. Often the third procedure involves secondary IOL implantation in aphakic patients or IOL repositioning in pseudophakic patients. Only eight patients (4.6%) required four operations, and one patient (0.6%) required five operations. These were exceptional cases that required either additional anterior chamber (AC) washout, IOL exchange, further glaucoma or retinal detachmnent (RD) surgery. In total, subsequent glaucoma surgery (n = 4) (2.3%) and RD surgery (n = 4) (2.3%) were uncommon, and corneal graft surgery was rare (n = 1) (0.6%).
Overall, none developed postoperative endophthalmitis and the median final IOP was 13 mmHg (range 5–57 mmHg). There were no statistically significant differences in the postoperative data between the group with good visual outcomes versus poor visual outcomes (Table 3).
Table 3. Identified postoperative factors.

4. Discussion

The reported incidence of dropped nucleus or nuclear lens fragment ranges from 0.1% to 1.8% [,,,,,,,]. Several publications only report the outcome of a cohort without indicating a denominator, i.e., the total number of consecutive phacoemulsification cataract surgeries carried out by their centres in a given time period. The overall incidence of dropped nucleus/fragment in our study is 0.19% over 5 consecutive years. This is in concordance with other large ophthalmic centres reporting a range of 0.044% to 0.3% [,,]. The EUREQUO dataset (6) is biased due to retrospective self-reporting by clinics and surgeons who voluntarily choose to participate in the registry compared to large ophthalmic centres where mandatory prospective data is collected daily in electronicmedical record systems.
In the literature, a final BDVA of ≥6/12 was seen in 53% to 72.3% of cases that included a dropped nucleus, and up to 85.2% of cases after excluding pre-existing ocular co-pathologies [,,,,,,]. In comparison we report favourable outcomes, including eyes with pre-existing co-pathologies and analysed them for associations with the final visual outcome. The risk factors presented in our study comprised those identified by Narendran et al. in 2009 associated with PCR and used in the two major UK EMR systems for Ophthalmology in the NHS ie Openeyes and Medisoft []. We also described risk factors associated with dropped nuclei in addition to those identified in the current Cataract National Ophthalmology Database (NOD) of the Royal College of Ophthalmologists []. A brunescent or white cataract was found to be significantly associated with a poor visual outcome. However, the other co-pathologies associated with increased PCR and dropped nuclei risk were not statistically significant for a poor visual outcome.
This was achieved through timely recognition and experienced emergent management by a senior surgeon during the initial complication. The prompt management during the initial procedure, minimising corneal oedema, for example, influences the timing of the secondary procedure and the final visual prognosis [,,,].
Early recognition of a PCR or zonular dehiscence reduces the risk of a dropped nucleus. In cases with a dropped nucleus, surgeons follow a structured anterior vitrectomy protocol described below. The first action would be early recognition, followed by injection of a cohesive ocular viscoelastic device (OVD) through a paracentesis to tamponade the vitreous face and minimise vitreous prolapse into the anterior segment and exit through corneal incisions. OVD is in addition employed to prevent any nuclear fragments that can be stabilised in the anterior chamber above the iris plane from prolapsing into the posterior segment. A dispersive OVD is used to protect the corneal endothelium. Preservative-free Triamcinolone acetonide is diluted 1: 6 with Balanced Salt solution, then injected into the anterior chamber to identify any vitreous strands and assist in performing a complete anterior vitrectomy. Retained vitreous strands are not only proinflammatory, leading to multiple sequelae such as CMO or raised IOP but also apply traction on the retina, which can lead to retinal tears or detachments.
After the vitreous is identified, anterior vitrectomy is performed using a bimanual technique. The instruments are inserted through the paracenteses with a vitreous cutter in one hand and the irrigation probe in the other. This step is crucial and limiting adjacent tissue damage is paramount to ensure secondary surgery can be carried out safely with visualisation through a clear rather than oedematous cornea.
Our standard practice is to insert a 3-piece intraocular lens (IOL), such as the Acrysof MA60AC (Alcon Inc., Geneva, Switzerland), with optic capture dependent on 360 degrees of continuous circumlinear anterior capsule integrity. Alternatively, the eye is left aphakic, and a planned secondary IOL implantation is dependent on age and endothelial cell count (Table 4). Anposterior chamber scleral fixated IOL is used in patients younger than 60 years and an anterior chamber IOL for those 60 years and older, with a good endothelial cell count if there is no option to employ sulcus placement. Dependent on excellent iris integrity and surgeon expertise an iris fixated IOL is employed without being age dependent.
Table 4. Potential intraocular lens options for cases with dropped nucleus.
At the end of the anterior segment surgery, the incisions should be closed with 10-0 nylon sutures to seal the wounds and mitigate the risk of endophthalmitis or hypotony. This provides a stable, closed system for the subsequent posterior segment surgery. The case is promptly discussed and handed over to the emergency vitreoretinal service for review and surgical planning according to an internal pathway.
There were no significant differences in the visual outcomes between consultant and resident grade ophthalmic surgeons, which suggests excellence in training and senior surgeon supervision. Surgical lists are typically run under consultant oversight, with the supervision of residents closely monitored and senior surgeons intervene early when an intraoperative complication occurs.
A possible explanation for poor visual outcomes associated with hypermature cataracts in our study is that white and brunescent cataracts are associated with a higher risk of both intraoperative and postoperative complications, not only including PCR, vitreous loss, dropped nucleus, but also inflammation, CMO, and endothelial damage. Dense nuclei can be more challenging to phacoemuslify, contributing to a higher cumulative dissipated energy (CDE) count, more postoperative inflammation, and worse visual outcomes or at least longer to reach the final visual endpoint [,,]. Identification of high-risk cases allows the team to prepare the patient accordingly and communicate the increased risk of poorer visual outcomes as part of the consent process and plan for a more experienced surgeon to complete a case.
In addition to experienced emergent surgical management, the use of IOP-lowering agents and cornea dehydrating topical treatment postoperatively is crucial in ensuring clear visualisation for the secondary procedure. If there are no contraindications oral Acetazolamide is given in the immediate postoperative setting and for the subsequent days until a PPV and a fragmatome are completed. g. Apraclonidine is administered until subsequent follow-up. In cases where corneal oedema is present or likely to develop, hypertonic g. Sodium Chloride 5% is used until the corneal clarity is achieved.
The management of a dropped nucleus or lens fragments into the posterior chamber is PPV with a fragmatome [,,,]. Alternative techniques have also been described in the literature to remove dropped nucleus/nuclear fragments, all of which emphasise the importance of protecting the corneal endothelium and ensuring a clear view [,]. It is therefore vital to ensure that outcomes of patients are closely monitored on an emergent basis [].
Our study reported a median time from primary cataract procedure to secondary PPV +/− fragmatome of 5 days. About two-thirds of cases had a secondary PPV within 1 week and over 90% within 2 weeks. The timing of early versus late PPV remains debatable. The timing of secondary surgical intervention necessitates a careful consideration of the risks associated with performing surgery in an acutely inflamed eye, in contrast to the potential for prolonged ocular inflammation resulting from the retention of nuclear material.
The conventional school of thought was that delaying the secondary PPV would enable time for the acute inflammation and corneal oedema to settle, providing the vitreoretinal surgeon with a clearer view. It also enables hydration of the lens nuclear material for easier removal with the fragmatome. While this has its merits, better understanding of the pathophysiology of the sequelae of dropped nucleus has led to a paradigm shift towards performing PPV and fragmatome as early as logistically feasible. An observational study comprising histopathological analyses of vitreous specimens from 135 patients showed that the number of inflammatory cells increases with time to PPV. No cells were found in the eyes that underwent vitrectomy within 3 days of primary procedure. This increased to 35% when PPV was performed 4–7 days after cataract surgery and 80% when performed at 61–90 days [].
There is also a growing body of evidence demonstrating the long-term sequelae of prolonged retention of lens material in the vitreous cavity. A systematic review of 43 studies and meta-analysis of 27 studies by Vanner et al. showed that each 1-week delay to PPV for retained lens fragments increased the odds of poorer outcomes in terms of VA, IOP, infection, and inflammation []. In contrast, several recent retrospective studies comparing early PPV within 1 week versus delayed PPV have not found any statistically significant differences in postoperative VA and IOP, and rates of RD, CMO, and raised IOP [,,]. The conflicting evidence in the literature indicates that both early and late vitrectomy can lead to favourable outcomes if primary complicated cataract surgery is performed with the intervention of an experienced surgeon.
Furthermore, in the Vanner et al.’s meta-analysis, only a delay beyond 2 weeks is considered statistically significant for overall poorer outcomes []. A recent study looking at the prognostic factors of 23-Gauge PPV for retained lens fragments following phacoemulsification found that delaying vitrectomy to later than 2 weeks was independently predictive of a VA of ≤6/60 []. Given that outcomes are generally favourable if vitrectomy is performed within 2 weeks, the window of opportunity would be between days 3 and 7, which avoids operating in the immediate period when the eye is most acutely inflamed from the primary procedure but is early enough to reduce the immune response to lens material that becomes more apparent from day 3 [].
The strengths of our study are that it utilises a large sample of consecutive phacoemulsification cataract surgery requiring secondary emergent fragmatome with no excluded records due to consistency in extracting data from the EMR. However, the main limitation of this study is its retrospective nature, which meant the “real-life” follow-up period and individualised treatment regimen were non-identical for all patients. Patient characteristics were limited to the available information on the EMR; factors such as patient symptomatology and treatment compliance could not be quantified unless specifically reported in the records.
Another limitation is that there may be confounding factors that are unaccounted for, despite the inclusion of risk factors known to increase the risk of PCR for analysis against visual outcomes. Equally, these factors may not necessarily be associated with a poor visual outcome, even though in the literature, they were associated with an increased PCR, e.g., type 2 diabetes mellitus, anddropped nucleus risk. Only one factor, hypermature cataract, was significantly associated with a poor visual outcome meant that further multivariate analysis was not relevant.
In our study there may also be inter-surgeon variability due to the study involving a large academic teaching hospital with multiple operating surgeons, including fellows and residents. However, being a single institution, there are clear guidelines for subsequent follow-up and a defined pathway to secondary surgery, and all cases are reported as a Serious Incident as per UK national reporting of surgical complications.

5. Conclusions

The dropped nucleus remains a challenging surgical complication with the potential for visually significant sequelae. Identifying high-risk patients via preoperative risk stratification allows the surgeon to prepare accordingly. A hypermature cataract was the most common ocular finding in patients with dropped nucleus, which significantly affected visual outcomes. However, overall incidence and outcomes of dropped nucleus cases were favourable despite the presence of pre-existing risk factors. This study describes the outcomes of a comprehensive approach to the management of dropped nucleus cases. It begins with meticulous surgical and medical management during the initial acute and subsequent postoperative period, followed by a prompt referral to the vitreoretinal surgeons for definitive management. A timely period between the initial complicated procedure and subsequent secondary procedure for removal of dropped nuclear lens material was reported in this study. This underscores the importance of emergent recognition and management of the dropped nucleus to facilitate the effective execution of secondary procedures, thereby achieving a favourable visual outcome.

Author Contributions

Conceptualization, S.R.K. and J.H.; methodology, J.H. and E.M.; software, J.H.; validation, S.R.K., E.M., M.-L.D., and N.M.; formal analysis, J.H.; investigation, J.H., E.M., M.-L.D., and N.M.; resources, S.R.K.; data curation, J.H. and E.M.; writing—original draft preparation, J.H., S.R.K.; writing—review and editing, E.M., M.-L.D., and N.M.; visualization, J.H.; supervision, S.R.K.; project administration, J.H. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki; ethical review and approval were not required for this type of study according to UK NHS Health Research Authority guidance.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
NHSNational Health Service
UKUnited Kingdom
CMOCystoid macular oedema
RDRetinal detachment
EMRElectronic medical records
PPVPars plana vitrectomy
VAVisual acuity
IOPIntraocular pressure
PCRPosterior capsular rupture
ALAxial length
PXFPseudoexfoliation syndrome
LALocal anaesthesia
BDVABest distance visual acuity
IOLIntraocular lens
CDECumulative dissipated energy

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Evaluating a Multi-Modal Large Language Model for Ophthalmology Triage
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