Acute intraoperative rock-hard eye syndrome and its management Oliver C.F. Lau, MB BS, BE, Jessica M. Montfort, MB BS, BA(Psych), Benjamin W.C. Sim, MB BS, Chris H.L. Lim, BMedSc, Tony S.C. Chen, MB ChB, MMed, Claire W. Ruan, MB BS, BMedSc, Ashish Agar, FRANZCO, PhD, Ian C. Francis, FASOPRS, PhD PURPOSE: To evaluate the use of pars plana needle aspiration of retrolenticular fluid in the imme- diate management of an acute intraoperative rock-hard eye syndrome (AIRES). SETTING: Private practice, Sydney, Australia. DESIGN: Retrospective case series. METHODS: Data over an 18-month period were collected to evaluate efficacy, complications, and visual outcomes in patients who had pars plana needle aspiration for management of AIRES, which is an acute intraoperative shallowing of the anterior chamber and a marked increase in intraocular pressure (IOP) during phacoemulsification cataract surgery but without evidence of a choroidal hemorrhage. Preoperative and postoperative (1 day, 1 week, and 1 month) data were evaluated. Resolution of AIRES and postoperative posterior segment status, IOP, and corrected distance visual acuity (CDVA) were the main outcome measures. RESULTS: Acute intraoperative rock-hard eye syndrome occurred in 6 (1.45%) of 413 surgeries. All 6 patients were women with a mean age of 81 years. Four patients had dense nuclear cataracts. In each case, the anterior chamber depth and IOP normalized immediately after pars plana needle aspiration and the procedure concluded uneventfully. Mild vitreous hemorrhage was observed in 1 patient postoperatively. At 1 month, the IOP was normal in 5 of 6 cases, while the CDVA was 20/12 in 5 of 6 cases. CONCLUSION: Although the etiology of AIRES is iatrogenic, immediate resolution was achieved un- eventfully with pars plana needle aspiration, which appears to be a safe management technique with satisfactory outcomes. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:799–804 Q 2014 ASCRS and ESCRS We have observed an ophthalmic surgical emergency that we call acute intraoperative rock-hard eye syn- drome (AIRES). The syndrome is characterized by acute intraoperative shallowing of the anterior cham- ber and a marked increase in intraocular pressure (IOP) during phacoemulsification surgery, but without evidence of choroidal hemorrhage. In the context of intracapsular cataract surgery (ICCE) and extracapsular cataract surgery (ECCE), this dyad of signs was not infrequently related to expulsive choroidal hemorrhage. 1 Fortunately, with the advent of small-incision techniques and phaco- emulsification, the occurrence of expulsive choroidal hemorrhage during cataract surgery has become rare. 2,3 The other differential diagnoses of acute anterior chamber shallowing and IOP elevation include ciliary block, 4,5 pupillary block, 6 capsule block, 7 air pupillary block glaucoma, 8 infusion misdi- rection syndrome, 9 and subcapsular fluid entrapment. 10 Over the past 39 years of cataract surgery, one of us (I.C.F.) had on rare occasions encountered cases of acute anterior chamber shallowing and IOP elevation during ECCE and phacoemulsification surgery that were not clinically consistent with any of the above entities. The anterior chamber shallowing and IOP elevation invariably developed within seconds and were sometimes accompanied by other features, including an inability to inject ophthalmic viscosurgi- cal devices (OVDs), iris prolapse, spontaneous Q 2014 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/$ - see front matter 799 http://dx.doi.org/10.1016/j.jcrs.2013.10.038 ARTICLE