7 EyeWorld Asia-Pacific | June 2025 FEATURE Fig 4: Lollipopping of small soft nucleus after hydrodelamination. Source: Ronald Yeoh, MD Fig 5: Layer of cortex after failed CCH. Source: Ronald Yeoh, MD fluid wave indicates good hydrodissection. However, we also know that the fluid wave is not seen in every case. So how then are we to know that hydrodissection is adequate? I teach my residents that there are 3 cardinal signs of adequate hydrodissection: 1. Fluid wave 2. Nucleus lift (Fig 2). This is a particularly useful sign! 3. Nucleus prolapse happens if excessive force is used; in this situation, either the posterior capsule ruptures with the snap sign or the nucleus prolapses out of the bag (if you’re lucky)! Whilst the nucleus lifting can often be seen down the microscope, it can be subtle and so three subsidiary signs are useful: 1. Dilation of the capsulorhexis (not so easily seen) and pupil (usually easily seen). 2. Cortical splitting in front of the nucleus. As the nucleus moves forwards, the overlying cortex can be seen to split apart. 3. Push-back sign. When the nucleus is lifted forward, pushing it back into the bag often results in a brisk pop as the nucleus goes back into the bag. This confirms the nucleus lift. The three main and three subsidiary signs of hydrodissection are most reliable and if they are seen, it is almost certain that hydrodissection freeing the nucleus has been achieved. In such cases, I find that rotating the nucleus is unnecessary. Tip: When hydrodissecting, I encourage my residents to hydrodissect to the right and left of the nucleus and avoid the area opposite the main incision. The reason is that when hydrodissecting opposite the main incision, the cannula may rest on top of the nucleus and prevent it from from lifting. Hydrodelamination Hydrodelamination is the perinuclear injection of fluid to isolate and free a small soft nucleus and is well typified by the appearance of a golden ring. (Fig 3) We typically do hydrodelamination in patients with a posterior polar cataract or in those with a soft, ambiguous nucleus. In polar cataracts, hydrodelamination reduces the risk of the fluid bursting through adjacent to the polar opacity. For soft cataracts typically in patients around 50 years old with mild nuclear sclerosis—successful hydrodelamination with golden rings usually means that I can “lollipop” the small nucleus onto my phaco tip, and it is then easily removed. (Fig 4) Care must be taken to remove the epinuclear shell that is left behind. Intraoperative OCT The introduction of intraoperative OCT (iOCT) on the operating microscope was a great help in studying and understanding the mechanics and fluidics of hydro maneuvers during phacoemulsification. It is worth noting that iOCT was initially designed and planned as imaging aids for lamellar corneal and macula surgery; not for phacoemulsification of cataracts. The use of iOCT was a significant development in helping us understand where the hydrodissection fluid planes were. I started exploring the application of iOCT in cataract surgery and scrutinized where the fluid waves went when we were doing hydrodissection and hydrodelamination. In hydrodelamination, it became very clear that the golden rings were caused by fluid in the perinuclear epinucleus, and there could be one or multiple rings present. (Fig 3). In hydrodissection, the dynamic studies showed that despite injecting fluid subcapsularly, the fluid wave was almost always at a level deeper than the lens capsule with a layer of lens cortex between the fluid and the posterior capsule. This finding becomes relevant in the next section.
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