Occult capsular injury in suspected traumatic and iatrogenic cataracts: a case report with imaging and pearls for surgical management.

Traumatic and iatrogenic cataracts may conceal occult capsular injury that routine slit-lamp examination and biometry fail to detect, increasing the risk of intraoperative complications. We present a mechanism-aware, imaging-guided approach to cataract surgery in an eye with suspected capsular compromise. An elderly man with a dense cataract and limited fundus view underwent preoperative imaging, which revealed a focal anterior capsular defect on ultrasound biomicroscopy, while posterior capsule integrity remained uncertain. His history included multiple intravitreal injections and prior anterior chamber paracentesis, raising suspicion for iatrogenic capsular injury. Given possible posterior fragility, surgery was performed using a noncontinuous curvilinear capsulotomy with radial relaxing incisions, low-vacuum and low-flow phacoemulsification, and contingency planning for capsular support and anterior vitrectomy. A monofocal intraocular lens was successfully implanted in the capsular bag without complication. This case highlights the importance of linking mechanism, targeted imaging (swept-source OCT or ultrasound biomicroscopy depending on media clarity), and a modified surgical strategy to reduce the risk of posterior capsule rupture and improve intraoperative preparedness.