8 EyeWorld Asia-Pacific | June 2025 FEATURE Cortical Cleaving Hydrodissection 30 years ago, the well known American cataract surgeon Howard Fine proposed the concept of Cortical Cleaving Hydrodissection (CCH) in which precise placement of the hydrodissection cannula under the anterior capsular rim resulted in hydrodissection cleaving a plane under the capsule that completely separates the cortex, epinucleus, and nucleus2. This meant that after removal of the nucleus, an empty bag was left behind, eliminating the need for irrigation/aspiration of the residual cortex! This was a very attractive concept indeed. Unfortunately it was not easy to achieve perfect CCH. Over the years, despite my trying to do so in every case, I was almost always left with a significant amount of residual lens cortex requiring irrigation/aspiration. It puzzled me as to why this was so. My analysis of the fluid wave location after attempted cortical cleaving hydrodissection showed that in almost every case, there was lens cortex left adjacent to the lens capsule; i.e., the CCH had failed (Fig 5). The fluid wave in nearly all cases found a deeper plane than intended. I hypothesize that this is related to corticocapsular adhesions, which prevent the fluid wave from separating the cortex from the capsule and instead direct it into the cortical layer3. These same adhesions also likely contribute to the variable force needed to hydrodissect and hence occasional intraoperative capsular block and hydrorupture. In an effort to determine if the failure was simply due to poor surgical technique on my part, I surveyed 20 internationally renowned cataract surgeons about whether they were able to achieve CCH always, frequently, occasionally, rarely or never. 90% answered “rarely” or “never” (as I found), and only two said they achieved it regularly! Other Complications Of Hydrodissection Another complication of hydrodissection is what I termed the pseudoexpulsive haemorrhage syndrome4. There is a scenario during hydrodissection in which the eyeball becomes rock hard, the anterior chamber shallows and the iris prolapses—simulating an expulsive haemorrhage. It becomes impossible to continue phacoemulsification. In this situation, fluid has loculated and become trapped behind the nucleus, but hydrodissection remains incomplete. This raises intraocular pressure, leading to the above signs. It is important to look for the red reflex as this helps distinguish this syndrome from a true expulsive haemorrhage in which case the red reflex would be lost. The management of this capsular block-related pseudoexpulsive syndrome is to insert a cyclodialysis spatula in front of the nucleus and ballot it several times, or simply press on the nucleus. Merely venting the anterior chamber is inadequate, as the fluid remains trapped. Balloting or pressing on the nucleus helps squeeze the fluid around it, completing hydrodissection and relieving the block. Typically, within a minute or two, the eye softens, the anterior chamber reforms, and surgery can be resumed. Relevance Of Hydrodissection Today As a technique that has been around for more than 30 years, is hydrodissection still relevant to the cataract surgeon today? The answer is… never more so!
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