Table 1.

Clinical manifestations of acute fluid misdirection syndrome

Article	Suggested name of syndrome	No. of eyes (incidence)	Performed procedure	Risk factors	Time of occurrence during surgery	Presumed pathomechanism	Suggested treatment	Outcome (follow-up period)
Kam et al. 2016 [2]	Acute intraoperative rock-hard eye syndrome	Two eyes (2/736 phaco procedures)	Phaco + IOL	N/A	During surgery (not described)	Freeing tenacious cortex, direct irrigation with a straight or a curved cannula of the inferior or superior capsular bag fornix, may contribute to finding materials in the vitreous. When repeated with a single, potentially powerful jet of balanced salt irrigated through a syringe and a cannula, may lead to transgression of the zonular apparatus by the balanced salt solution and small pieces of lens material.	Emergent pars plana needle aspiration of retrolenticular fluid with a 23-gauge needle	Good — AC deepening
Lau et al. 2014 [3]	Acute intraoperative rock-hard eye syndrome	Six eyes (6/413 phaco procedures)	Phaco + IOL	- Higher levels of AC irrigation - Hyperopia	Not only from the phacoemulsification but also from hydrodissection, hydrodelineation, and irrigation of the posterior capsule and equatorial cortex with a hydrodissection cannula.	Residual cortical fiber irrigation maneuver (when residual cortical fibers are being removed, the narrow stream of balanced salt solution generated by the narrow hydrodissection cannula tip may distort the posterior capsule locally) resulting in localized anterior displacement of the contiguous posterior capsule, creating a subcapsular or vitreal space through which the balanced salt solution may move via the zonular fibers.	Emergent pars plana (3 mm from limbus) needle aspiration of retrolenticular fluid with a 23-gauge needle	Good post-op visual acuity and normal IOP. Complications: - mild vitreous hemorrhage (one eye) - temporal arteritis (one eye 1 month post-op)
Mackool et al. 1993 [4]	Infusion misdirection syndrome	N/A	Phaco + IOL	- Exfoliation - Dense/brunescent cataract	During surgery, especially at the time of removal of the last nuclear pieces	Aqueous can be directed posteriorly behind an intact lens and cause chamber shallowing: - when fluid passes through an opening in the posterior capsule or the equatorial region (especially likely after can-opener capsulotomy or radial extension of capsulorhexis), permitting direct access to the retrocapsular space - in the presence of an intact capsule (intact rim by capsulorhexis) fluid passes through the region of the zonular fibers. More commonly in association with lax zonular fibers	- Viscoadaptive agent to the AC - Pars plana decompression	N/A
Olson et al. 1994 [5]	Subcapsular fluid entrapment	Five eyes	Penetrating keratoplasty + ECCE + IOL (two eyes) phaco + IOL (three eyes)	- Open sky I/A - Zonular dialysis	During surgery	- Irrigation anterior to the AC flap - Zonular dehiscence	- Dry aspiration (three eyes) - Pars plana paracentesis (one eye) - Spontaneous central capsule rupture (one eye)	Good — AC deepening Paracentesis unsuccessful in one eye — IOL implanted 2 months post-op
Dewey 2011 [6]	Intraoperative fluid misdirection	Three eyes	Phaco + IOL	- Coughing - Short axial length - Significantly intumescent lens	During surgery	N/A	- Viscoadaptive agents to the AC and dry aspiration (mild cases) - Sharp needle decompression, or automated vitrectomy handpiece to avoid potential vitreous traction (severe cases) - Benzonatate capsules (Tessalon Perles) for patients with a history of coughing, “sinus drainage,” chronic obstructive pulmonary disease, bronchitis, asthma, sleep apnea, snoring, use of supplemental oxygen, difficulty breathing in the supine position for any reason, and at the preoperative nurse’s suspicion.	Good — AC deepening
Grzybowski et al. 2014 [7]	Acute / chronic aqueous misdirection syndrome	N/A	Phaco + IOL	N/A	During surgery - toward the end of irrigation/aspiration	Inappropriate “movement of the balanced salt solution via the zonular fibers” triggered by the unconventional use of the residual cortical fiber irrigation maneuver	Pars plana decompression with vitreous cutter	Good — AC deepening
Wu et al. 2016 [8]	Malignant glaucoma	Thirty-eight eyes (of 1432 eyes undergoing anti-glaucoma surgical treatment for primary angle closure glaucoma)	- After trabeculectomy (32 eyes — 84.2%) - during trabeculectomy (four eyes — 10.5%) - after combined glaucoma/cataract surgery (two eyes — 5.3%)		During or after surgery	1) Ciliolenticular block or anterior hyaloid obstruction 2) Slackness of lens zonules 3) Severe postoperative inflammation 4) Non ciliary block. It was observed that those patients who developed malignant glaucoma during surgery all showed a high stress level and poor operative cooperation. We speculated that such status caused constriction of extraocular muscles pressing forward, bringing about the increase of ocular venous pressure.

Abbreviations used: AC, anterior chamber; ECCE + IOL, extracapsular cataract extraction with intraocular lens implantation; I/A, irrigation/aspiration; IOL, intraocular lens; IOP, intraocular pressure; phaco + IOL, phacoemulsification with intraocular lens implantation