Vitreous hydration is a subtle but impactful phenomenon during cataract surgery. I believe lesser degrees of vitreous hydration may occur more often than surgeons recognize and can contribute to intraoperative challenges and postoperative complications. Understanding and managing this phenomenon is therefore essential for optimizing your surgical outcomes and patient safety.

UNDERSTANDING VITREOUS HYDRATION

Factors Influencing Risk

Zonular permeability varies widely across patients. Healthy zonules often serve as an effective barrier, but eyes with pseudoexfoliation syndrome, advanced age-related zonulopathy, high myopia, or prior vitrectomy have increased susceptibility. Moreover, surgical factors heavily influence risk: high infusion pressures combined with low vacuum settings can elevate fluid flow and pressure in the anterior chamber, promoting vitreous hydration even in otherwise low-risk eyes.

Mechanism and Impact

Semipermeable zonules can allow irrigation fluid—and sometimes lens fragments—to seep posteriorly without obvious visual clues. Typically, you might suspect this when small fragments of nucleus or cortex become inaccessible behind the posterior capsule during cortical cleanup. Unfortunately, once lens material enters the vitreous, there is little you can do intraoperatively to address it.

Aside from mechanical disruption of the vitreous architecture, which can increase the risk of retinal tears or detachment, fluid and debris in the vitreous contribute to postoperative inflammation, cystoid macular edema, and patient complaints such as floaters. Prevention is therefore paramount.

MITIGATING VITREOUS HYDRATION

Recent advances in phaco technology (see the sidebar)—such as lower infusion pressure with higher vacuum, stabilized fluidics, and anterior chamber sensors—are promising for mitigating vitreous hydration.

In everyday practice, though, vitreous hydration can be minimized through conscious surgical technique:

• Optimize fluidics. Use lower infusion pressures and carefully balanced vacuum settings to maintain a stable anterior chamber without excessive turbulence.
• Tailor surgery to patient anatomy. Recognize risk factors such as weak zonules, pseudoexfoliation, prior vitrectomy, and intraoperative floppy iris syndrome and adjust settings accordingly.
• Maintain efficient surgery. Prolonged surgery increases fluid exposure and the risk of hydration. Pharmacologic agents such as phenylephrine 1% and ketorolac 0.3% (Omidria, Rayner) can help sustain dilation and facilitate quicker procedures.
• Be vigilant. Be alert for subtle signs such as inaccessible cortical fragments behind the posterior capsule, which may hint at fluid passage into the vitreous.

No single approach fits all cases. The key is individualized management—adjusting your fluidics and technique based on cataract density, zonular integrity, pupil size, and surgical experience.

A CALL FOR INTENTIONALITY

Subtle vitreous hydration remains largely overlooked in surgical education and the peer-reviewed literature. The opportunity for improvement is significant. By intentionally adjusting fluidics management as part of a broader patient-centered approach, you can better protect patients against subtle yet clinically meaningful complications.