OBJECTIVE To evaluate the effect of primary posterior continuous curvilinear capsulorhexis (PCCC) with and without posterior optic buttonholing (POBH) on the anterior chamber reaction after small-incision cataract surgery. METHODS Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS Consecutive patients with age-related cataract having cataract surgery in both eyes under topical anesthesia were prospectively enrolled in a randomized clinical trial. In randomized order, cataract surgery with combined primary PCCC and POBH was performed in 1 eye; in the other eye, cataract surgery was performed with primary PCCC and in-the-bag implantation of an intraocular lens. Intraocular flare was measured with an FC-1000 laser flare-cell meter preoperatively and postoperatively at 1, 4 to 6, and 24 hours, 1 week, and 1 month. RESULTS Thirty patients (60 eyes) were evaluated. The peak of intraocular flare was 1 hour postoperatively in all study eyes. In both groups, the response steadily decreased thereafter. Anterior chamber flare was statistically significantly higher in eyes with primary PCCC without POBH than in eyes with combined primary PCCC-POBH at all postoperative testing points (P<.001), including at 1 month (P = .01). CONCLUSIONS Cataract surgery with combined primary PCCC-POBH led to significantly lower postoperative anterior chamber reaction than conventional in-the-bag implantation during a 4-week follow-up. The tight capsule-optic diaphragm effectively prevented the ophthalmic viscosurgical device captured behind the optic from entering the anterior chamber postoperatively.