Between a Rock-Hard Cataract and a Successful Phaco

William W. Culbertson, MD


August 18, 2014

Acute Intraoperative Rock-Hard Eye Syndrome and Its Management

Lau OC, Montfort JM, Sim BW, et al
J Cataract Refract Surg. 2014;40:799-804

A Perplexing Quandary

Most surgeons have observed a phenomenon that occurs during phacoemulsification cataract surgery in which the anterior chamber shallows and the globe becomes firm, making the remainder of the surgery difficult or complicated. The differential diagnosis includes suprachoroidal hemorrhage or effusion and misdirection and entrapment of balanced salt solution (BSS) in the vitreous or behind the posterior capsule. Although surgeons may face this dilemma only rarely, differentiating the possible etiologies quickly and having a plan to effectively deal with each possibility is challenging.

When the surgeon has excluded suprachoroidal causes by ophthalmoscopy, a perplexing quandary remains. The surgeon must choose between pressing onward with the surgery, thereby risking breaking the posterior capsule and injuring the iris; aborting the procedure; or reducing the positive vitreous pressure in some way.

Study Summary

Lau and colleagues reviewed the occurrence of what they call "acute intraoperative rock-hard eye syndrome" (AIRES) in a consecutive series of 413 clear corneal phacoemulsification procedures by the same surgeon. They discovered 6 cases that qualified, with the onset during aspiration of the residual lens cortex. In each case, the process resolved with pars plana aspiration of 0.1-0.3 mL of retrolenticular fluid with a 23-guage needle and a 3.0-mL syringe. This resulted in immediate softening of the eye and return of the anterior chamber dimensions to normal levels.

The investigators postulated that irrigation of the posterior chamber/capsular bag allowed BSS to be misdirected through defects in the zonular barrier into the space behind the capsule or in the anterior vitreous gel. Although they pointed out that aspiration of a small amount of liquid in the space behind the capsule was enough to change how BSS was retained in the vitreous space, they did not elaborate on the mechanism that produced this change.


Similar syndromes are often encountered by ophthalmologists during phacoemulsification, nuclear emulsification, or cortical aspiration. Although there is debate on the anatomic etiology and where behind the capsule the BSS is captured, the common pathogenesis is a misdirection and misaccumulation of BSS in the anterior vitreous compartment.

Once suprachoroidal causes are excluded ophthalmoscopically, the surgeon can aspirate collected fluid or perform an automated anterior vitrectomy through the pars plana and expect resolution of the problem. There is no need to abort the case or proceed with great peril when a simple excursion with a needle or vitrectomy needle into the anterior vitreous compartment under direct transpupillary observation saves the day.


Suggested Reading

Chang DF. Pars plana vitreous tap for phacoemulsification in the crowded eye. J Cataract Refract Surg. 2001;27:1911-1914.

Mackool RJ, Sirota M. Infusion misdirection syndrome. J Cataract Refract Surg. 1993;19:671-672.

Osher H. Causes and management of intraoperative shallowing of the anterior chamber. J Am Intraocul Implant Soc. 1984;10:361-362.


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