6 EyeWorld Asia-Pacific | June 2025 FEATURE Binkhorst Lecture, presented at the 2025 ASCRS Meeting in Los Angeles by Ronald Yeoh, MD This article is based on the Binkhorst Medal lecture titled “Hydro Chronicles” which I presented at the April 2025 ASCRS Meeting in Los Angeles, USA. My interest and love affair with hydrodissection started in 1993 when I was a young and inexperienced phaco surgeon. I had been dissatisfied with my hydrodissection technique and thought that hydrodissection through the side port would be more efficient as the anterior chamber would be more watertight. Unfortunately, as I hydrodissected through the side port, the pupil abruptly constricted and this was followed shortly by the nucleus tilting and descending into the vitreous cavity. I managed to retrieve the nucleus using a Vectis and after an anterior vitrectomy was able to implant a three-piece IOL into the sulcus. What I had witnessed was the “pupil snap” sign of hydrorupture of the posterior capsule, and I published this in the BJO in 19951. The “pupil snap” sign occurs when excessive force is used during hydrodissection and the fluid that is injected ruptures the posterior capsule instead of going all the way around the nucleus to the other side. (Fig 1) As the posterior Fig 1: Hydrorupture of the posterior capsule. Source: Ronald Yeoh, MD Fig 2: The nucleus lift sign. Source: Ronald Yeoh, MD Fig 3. Golden rings of hydrodelamination. Source: Ronald Yeoh, MD Hydro Chronicles capsule ruptures, the nucleus abruptly descends away from the iris and this posterior movement triggers the pupil to constrict. Recognition of the “pupil snap” sign is important because steps can be taken to do “slow motion” phaco at lowered parameters which reduces the risk of a nucleus drop or at the very least, the surgeon is prepared with vitreo-retinal backup. If there is one good thing about a hydrorupture of the posterior capsule, it is that the anterior capsular rim is usually unaffected and a three-piece IOL is easily inserted into the sulcus. Tip: Avoid hydrodissection through the side port. This complication stimulated my interest in hydrodissection and hydrodelamination and over the past 30 years, I have studied and analyzed these maneuvers carefully. Standard Hydrodissection Hydrodissection to free the nucleus is the cornerstone of most nuclear removal techniques in phaco. Every cataract surgeon is aware that the occurrence and sighting of the
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