1. Dr. Navin Gupta M.S. Shankar Netrika Eye Hospital, Mumbai

2. Introduction  Irrigating fluid is injected through a cannula into various anatomical layers of lens  First described by Bluementhal  Term given by Faust

3. Michael Bluementhal

4. Intro  Include hydrodissection and hydrodelineation  Mobility of lens complex with in capsule  Extended the inherent advantage of CCC in SICS & Endocapsular Phaco

5. Hydrodissection  Injecting fluid between anterior capsule and cortex  First described by Faust for ECCE  Its applicability recognized in Phaco

6. Hydrodissection

7. Aim Mobilize the nucleus within the capsule for disassembly and removal

8. Technique  Tradition Hydrodissection  Injecting fluid into cortical layer  Gimbel, Fine & Poley  Before hydrodissection anterior flap of capsule is tented/elevated by canula  Hydrofree dissection

9. Technique  4 - 5mm CCC  26g Blunt Cannula  Anterior capsule is elevated away from cortex  Injection site near lens equator

10. Technique  Gentle continuous irrigation  Lens bulges anteriorly  Decompress the lens to break equatorial adhesions  Care taken not to prolapse the nucleus  Slow decompression

11. Phenomenon to watch for during hydro  Advancement of fluid wave  Anterior movement of nucleus  Stretching of CCC  Shallowing of anterior chamber

17. Cortical-Cleaving Hydrodissection

18. Cortical cleaving hydrodissection

20. Conventional hydrodissection

21. Hydrodissection

22. Advantages of Hydrodissection  Improved maneuverability of lens  Rotation freely in the bag  With cortical HD - reduces the usage of I & A hand piece

23. Hydrodelination  Separation of outer epinuclear shell from central compact endonucleus by forceful irrigation of fluid

24. Hydrodelination  Anis introduced basic concept  Injecting fluid directly into lens matter  Allows the nucleus to be cracked into layers or softened by hydration  Also referred as hydrodemarcation or hydrodelamination

25. Technique of Hydrodelination  Better to do after hydrodissection  Inserting cannula between hard core nucleus and epinucleus (DMZ)  Cleavage plane  superficial in hard nucleus  centrally in soft nucleus  Results in golden ring

26. Hydrodelination  26g Blunt Cannula  Pass into the substance of nucleus till nucleus moves  Create a tract by to and fro movement of cannula  26g Blunt Cannula  Pass into the substance of nucleus till nucleus moves  Create a tract by to and fro movement of cannula

27. Hydrodelination  Withdraw cannula half way  Gentle steady pressure on plunger  Fluid will find path of least resistance and flows circumferentially  Golden ring reflex  Withdraw cannula half way  Gentle steady pressure on plunger  Fluid will find path of least resistance and flows circumferentially  Golden ring reflex

30. Hydrodelination

31. Advantanges of Hydrodelination  Cushion like effect of the epinucleus  Minimize potential damage to PC/capsular fornix and endothelium  Shielding effect - particularly important in cases with dense nuclei

32. Advantage of Hydrodelination  Reduce volume of central portion of nuclei removed by Phaco  Less deep & less periphery grooving  Quadrant more early mobilised after cracking/chopping

33. Challenges of Hydroprocedures  Attempting in presence of PC Rent  Spread nuclear fragment into vitreous  Surgeons experience & confidence - hydroprocedures present no additional risk

34. Complications  Posterior capsule rupture  Dislocation of lens into vitreous  Pupillary snap sign  Posterior capsule rupture  Dislocation of lens into vitreous  Pupillary snap sign

35. Special situations  No HD in mature cataract  PPC  Small pupil  Weak zonules