Acute Intraoperative Rock-Hard Eye Syndrome

A 74-year-old female with diabetes, hypertension, and a cardiac pacemaker presented with right-eye visual acuity of hand motion due to a mature cataract. Intraocular pressure was 16 mmHg bilaterally. Biometry showed an axial length of 22.38 mm, anterior chamber depth of 2.13 mm, lens thickness of 5.63 mm, central corneal thickness of 548 µm, and white-to-white corneal diameter of 11.35 mm, consistent with a relatively large lens in a crowded anterior segment. Phacoemulsification with intraocular lens implantation was planned.

At the beginning of surgery, prior to capsulorhexis, the eye became acutely rock-hard. The anterior chamber was shallow, and the iris–lens diaphragm was anteriorly displaced. Differential diagnosis was performed intraoperatively to exclude suprachoroidal hemorrhage and other causes of positive vitreous pressure. The findings were recognized as acute aqueous misdirection, and the decision was made to continue surgery rather than abort. Intracameral air injection was performed to deepen the anterior chamber and relieve the pupillary block component, followed by rapid phacoemulsification. The anterior chamber deepened promptly, and IOP normalized. Posterior capsular ondulation and lens fragments in the Berger space were observed, suggesting zonular weakness and posterior fluid misdirection. The rock-hard eye resolved without pars plana tap or vitrectomy. The anterior chamber deepened promptly, and surgery was completed uneventfully without complications.