9 EyeWorld Asia-Pacific | June 2025 About the Physician Ronald Yeoh, MD | Consultant Eye Surgeon & Medical Director, Eye & Retina Surgeons | Clinical Associate Professor, Duke-NUS Grad Med School, Singapore National Eye Centre | ry@ers.clinic Relevant Disclosures Yeoh: None References 1. Yeoh R. The ‘pupil snap’ sign of posterior capsule rupture with hydrodissection in phacoemulsification. Br J Ophthalmol; 1996 May;80(5):486 2. I Howard Fine. Cortical cleaving hydrodissection. J Cataract Refract Surg. Volume 18, Issue 5, September 1992, Pages 508-512 3. AR Vasavada, D Goyal, L Shastri, R Singh. Corticocapsular adhesions and their effect during cataract surgery. J Cataract Refract Surg. 2003; 29: 309-314 4. R Yeoh, J Theng. Capsular block syndrome and pseudoexpulsive haemorrhage. J Cataract Refract Surg. 2000 Jul;26(7):1082-4 5. Roberts TV, Sutton G, Lawless MA, Shveta JB,Hodge C. Capsular block syndrome associated with femtosecond laser assisted cataract surgery. J Cataract Refract Surg. 2011; 37:2068-2070 6. Yeoh R. Hydrorupture of the posterior capsule in femtolaser cataract surgery. J Cataract Refract Surg. 2012; 38:730 7. Chang, David F.; Campbell, John R. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg; 31(4):664-673, April 2005 8. Ishtiaque A, Rahman Sharah. Sleeve hydrodissection: An innovative hydrodissection technique for IFIS. Submitted to JCRO 9. Osher R. Yeoh R. Riding the hydrodissection wave. J Cataract Refract Surg. 49(7):657-658, July 2023 1. Femtosecond laser assisted cataract surgery (FLACS) In the last decade or so, there have been proponents and detractors of FLACS in cataract surgery. In a very early case report, Roberts et al. described two cases of dropped nuclei during FLACS5. In subsequent correspondence and discussion, it became apparent that the dropped nuclei were related to performing “normal” hydrodissection after the femtosecond laser had been applied6. Gas bubbles produced during laser fragmentation of the nucleus increase intralenticular pressure. It is hypothesized that adding hydrodissection fluid into this pressurized space raises the pressure further, potentially rupturing the posterior capsule. Today, we aim to use less laser energy to reduce gas production and recognize the importance of allowing gas to escape from behind the nucleus before hydrodissecting. Some surgeons omit the hydrodissection step entirely in FLACS cases. 2. Pre-existing posterior capsular weakness or tears The example par excellence is of course the posterior polar cataract in which we have long known that we should not hydrodissect, but should hydrodelaminate instead to avoid the fluid wave bursting through a weaked posterior pole of the lens. Hydrodelamination is of course at a deeper plane, further from the posterior polar element. Today however, there are several other clinical scenarios in which the posterior capsule may already be ruptured pre-operatively. These include patients with: - Needlestick or other injuries - Prior intravitreal injections - Subretinal fluid drainage during scleral buckling - Iatrogenic lens touch during vitrectomy - YAG laser vitreolysis (Fig 5) The common factor in all these conditions is that the patient develops a significant cataract rapidly within hours or days of the offending iatrogenic procedure. This clinical scenario should alert the surgeon to the possibility of a pre-existing capsular defect, in which case hydrodissection should be performed with great caution, if at all. 3. Idiopathic Floppy Iris Syndrome (IFIS) We recognize the triad of iris behaviour in IFIS during cataract surgery: - A billowing, floppy iris - Progressive intraoperative miosis - Significant iris prolapse7. Clearly, hydrodissection in a patient with IFIS may aggravate the tendency to iris prolapse—bearing in mind that even in non-IFIS eyes, inexperienced surgeons may still encounter this complication. Ahmed et al proposed an interesting technique to reduce the risk of intraoperative iris prolapse in IFIS patients: performing hydrodissection with a phaco sleeve placed over the hydrodissection cannula. The sleeve sits in the main incision and tamponades the iris while also providing a venting pathway for hydrodissection fluid accumulating in the eye8. This allows the fluid to bypass the iris. Conclusion So we have come full circle— re-examining hydro maneuvers in a new light, aided by new technology. Today, hydrodissection remains as relevant as ever9. I hope the oft-neglected step of hydrodissection will now be viewed with renewed appreciation.
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