In cataract surgery, managing a small pupil presents several intraoperative challenges, particularly in safely prolapsing the nucleus out of the capsular bag. One effective technique to address this is careful hydro-dissection. After a complete and well-centered capsulorhexis is created, hydro-dissection should be performed slowly and deliberately. A blunt cannula is inserted under the capsulorhexis edge, and a small amount of balanced salt solution (BSS) is injected to cleave the cortex from the capsule without causing posterior capsular pressure spikes. Gentle fluid waves should be observed traveling across the posterior surface of the lens.
The goal is to mobilize the nucleus without rupturing the posterior capsule or stressing the zonules. Once the initial wave is visualized, the surgeon can gently depress the posterior pole of the nucleus to encourage the opposite edge of the lens to rise. This maneuver should be performed incrementally, repeating small, targeted hydro-dissection in different quadrants to ensure even release.
As one quadrant of the nucleus elevates, a second instrument can assist in prolapsing the nuclear pole out of the bag and into the anterior chamber. This step is especially useful in cases with smaller pupils, where direct visualization of the peripheral capsule is limited. Proper hydro-dissection minimizes mechanical manipulation, reduces iris trauma, and allows for safer nuclear delivery with improved control.
