Operating Under Pressure – Incidence And Management Of Acute Intraoperative Rock-Hard Eye Syndrome During Cataract Surgery Causing Delayed Completion Of Surgery
Published 2026 - 44th Congress of the ESCRS
Reference: POCAT217 | Type: Free paper | DOI: 10.82333/ftym-5y52
Authors: Mr Sinmiloluwa Tokede* 1 , Dr Zain Charfare 2 , Dr Ayley Loh 3 , Ms Emily Pinkney 4 , Dr Bimal Kumar 5 , Dr Anant Sharma 5
1Cambridge University,Cambridge,United Kingdom, 2Singleton Hospital,swansea,United Kingdom, 3North west Anglia NHS foundation trust,Peterborough,United Kingdom, 4Queen's university Belfast,Belfast,United Kingdom, 5Newmedica,Northampton,United Kingdom
Purpose
To determine the incidence of “hard eye” during phacoemulsification cataract surgery, and to evaluate outcomes following medical management with delayed completion of surgery at a single eye centre.
Setting
Single high-volume specialist eye centre, over a 43-month period.
Methods
Retrospective review of all consecutive phacoemulsification and intraocular lens insertion procedures performed over a 43-month period (11,600 eyes). Case documenting an intraoperative hard eyes were identified. Operative recordings and case notes were analysed to classify underlying cause (aqueous misdirection, subchoroidal haemorrhage (SCH) or choroidal effusion), stage of surgery at abandonment, management strategy, biometry and epidemiological data.
Results
Among 11,600 eyes, 14 cases (0.12%) of intraoperative hard eye were identified: 10 aqueous misdirection (0.09%), 2 SCH (0.02%), and 2 choroidal effusion (0.02%). Surgeries were abandoned at various stages and managed with oral acetazolamide and topical intraocular pressure-lowering therapy as well as increased frequency of dexamethasone and ketorolac drops postoperatively prior to delayed completion. All completed cases achieved successful intraocular lens insertion within the capsular bag. Maximum delay to completion was 77 days; one patient remains awaiting secondary surgery. The most common complication was iris trauma (4 cases).
Conclusions
Intraoperative hard eye during cataract surgery is rare but clinically significant. In this series, aqueous misdirection was more common than SCH and choroidal effusion. Medical reduction of intraocular pressure with planned delayed completion allowed safe secondary surgery with successful capsular bag intraocular lens implantation in all completed cases. This conservative strategy represents a pragmatic and reproducible management approach for surgeons encountering this complication in routine cataract practice.