Reply.

Abstract

In our article, the evidence of anterior vitreous detachment (AVD) during phacoemulsification was verified with intraoperative optical coherence tomography. We postulate that the condition being linked to cataract surgery complications. The major intraoperative issue resulting from AVD is bulging of the posterior capsule (PC) being pushed from behind toward the anterior chamber by the irrigating fluid currents. That results in PC rupture due to its contact with a vibrating ultrasound needle or capsule aspiration into the irrigation/aspiration tips. Both are usually happening at the final steps of lens removal. AVD is having various definitions in different publications. The plurality of terms describing more or less the same entities reflects the absence of clear understanding of the pathophysiological mechanisms of these conditions.1,2 We basically agree with the fact that there is an unmet need for the precise terminology that has to be clear and precise. Aqua is the Latin word meaning water, whereas aqueous is an adjective, generally used as a term that denotes a solution in which the main solvent is water. It is important not to confuse this with the term aqueous humor, which is secreted by intraocular tissues.3Aqueous misdirection does not clearly characterizes the deviated flow of a balanced salt solution but rather the deviated flow of the aqueous humor. Fluid is a phase of matter and is defined as a substance that flows. A fluid can be in different forms of liquid or gas.A This term is less specific in comparison with the term aqueous. But indeed, it is routinely used in ophthalmology to describe the accumulation of pathologic liquids in the eye, eg, subretinal fluid and corneal interface fluid after refractive surgery. The term fluid to our knowledge is more universal in comparison with aqueous, and its use in our situation might be more appropriate. However, it is still very broad and not specific enough; therefore, we do believe that infusion misdirection syndrome or irrigating fluid misdirection syndrome might be more clear and practical to use. The first term is shorter and well describes the major aspect of the pathophysiology based on the abnormal flow of the irrigating fluid or infusion. That is why it is our personal preference. We also propose the new classification of infusion misdirection syndrome that explains the acute intraoperative process. The initial grade is usually subclinical and may be hardly noticeable by the presence of the lens particles in the Berger's space (grade 1). The mild grade (2) can be characterized by shallowing of the anterior chamber with PC bulging forward up to the level of the anterior capsulorhexis, but without intraocular pressure elevation. Finally, the severe grade (3) is the condition originally classified as an acute intraoperative rock-hard eye syndrome, which is the term that underlines the advanced stage of infusion misdirection syndrome with the presence of acute intraoperative intraocular pressure rise. We do believe that malignant glaucoma is a different entity. It is usually associated with the fluid accumulation in between the retina and posterior vitreous in the postoperative period, resulting in the displacement of the whole vitreous forward blocking the anterior pathways of aqueous humor outflow. We therefore think that chronic fluid misdirection syndrome does not really emphasize the progressive nature of that disease leading to visual and structural deterioration.4 That is why we think that the definition of malignant glaucoma is to be used as it is.