A multipronged approach to prevent Argentinian flag sign in intumescent cataracts

Midperipheral mini-capsulorhexis as an additional step for safe phacoemulsification in white intumescent cataracts

The present article describes a novel surgical technique of a primary mini-capsulorhexis in midperiphery to minimize surgical complications in white intumescent cataracts. Patients with white mature cataracts with a convex anterior capsule or swollen lens fibers were selected. An initial puncture was made 3-4 mm away from the center, in the midperipheral anterior capsule, with a conventional cystitome. A mini-capsulorhexis (2-2.5 mm) was created. Loose cortical matter and fluidic contents were aspirated to reduce the intralenticular pressure. Two cuts were made at the margin of the mini-capsulorhexis, and an adequately sized secondary rhexis was completed, after which phacoemulsification was done. A circular curvilinear capsulorhexis was successfully achieved in all cases, including those with a small pupil. Rhexis could be completed in a patient where an initial extension occurred due to head movement. This refined technique aims to enhance the safety and precision of capsulorhexis in intumescent cataracts, thereby reducing the risk of complications such as the Argentinian flag sign. Further exploration and validation of this approach through clinical trials are warranted to establish its efficacy and safety profile.

Double peak sign on ultrasonography: A new prognostic marker before surgery for white cataract

A mature, hypermature, or white cataract needs posterior segment evaluation before surgery for prognostification. Ultrasonography is the preferred method for this. White cataract or intumescent cataract risks intraoperative capsulorhexis running out leading to devastating complications due to high intralenticular pressure. Altghough sligh-lamp examination before surgery can gives clue regarding fluid pockets under anterior capsule in these types of cataract, fluid in posterior compartment of lens can be detected by ultrasonography. The author here described a new sign, the double peak sign which can predict the high intra-lenticular pressure especially in posterior compartment of the lens. So if it detected before surgery, all precautions can be taken during surgery to prevent complications. The A-scan overlay on the B-scan in ultrasonography can detect the hypoechoic area corresponding to the lequified cortex in between solid lens nucleus and posterior capsule, so giving rise to the double peak sign which is described here as an innovation.

Preventing the Argentinian flag sign and managing anterior capsular tears: A review

The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule.

Capsulorhexis with 23-gauge vitreous cutter in intumescent cataract surgery: Case series

A capsulorhexis technique with a 23-gauge vitreous cutter in intumescent cataract surgery is presented. These patients have a high risk of uncontrollable extension of the opening of the anterior lens capsule. We used vitreous cutter for capsulorhexis along with the other steps performed as in standard phacoemulsification surgery. This technique allows controlled capsulorhexis and may be an alternative method in patients with intumescent cataracts with high intralenticular pressure and absence of red reflex.

Sewing needle microcapsulotomy to avert Argentinian flag sign

The Argentinian flag sign is a known complication in intumescent white cataracts, which arises instantly after an initial prick with a sharp hypodermic needle on a stretched out anterior capsule. Increased intralenticular pressure is believed to be responsible for propagation of the initial prick into a radial capsular tear. However, it is the linear cut configuration of the initial prick, created by the hypodermic needle on the tense anterior capsule, which spontaneously opens up and propagates toward the periphery along its margins. To overcome this, a new instrument was devised, sewing needle microcapsulotome, to puncture the capsule and create a single or multiple round openings with smooth margins, allowing the bag to decompress satisfactorily without yielding to disruptive intralenticular forces. This technique of sewing needle microcapsulotomy, to prevent the Argentinian flag sign, was found to be highly effective and safe in a series of surgeries on intumescent cataracts.

Role of Preoperative Nd:YAG Laser Anterior Capsulotomy in Mature Intumescent Cataracts

PURPOSE

The aim of this study was to examine the role of preoperative Nd:YAG laser anterior capsulotomy in preventing intraoperative complications in mature intumescent cataracts.

DESIGN

A prospective, interventional, observational study.

METHODS

A total of 52 eyes of 52 patients were selected in this prospective study. Preoperative Nd:YAG laser anterior capsulotomy was performed in all eyes with 1 shot of 1.2 mJ and a gush of the liquified cortex was noted. Anterior chamber depth was measured using anterior segment optical coherence tomography and intraocular pressure using Goldmann applanation tonometer were measured pre- and post-laser. Intraoperative complications and surgeon's operative comfort were noted.

RESULTS

There was a mean increase in anterior chamber depth by 0.24 mm and a mean decrease in intraocular pressure by 1.61 mm Hg postlaser. No intraoperative complications were noted except for capsulorhexis extension in 1 eye (1.92%). The surgeon experienced a good control while performing the capsulorhexis and overall an uneventful surgery.

CONCLUSIONS

Preoperative Nd:YAG laser anterior capsulotomy is a safe and effective technique in reducing intralenticular pressure and avoiding intraoperative complications in mature intumescent cataracts.

Modified capsulorhexis for fiuid-filled mature cataracts

Background

The aim of this study was to develop a modified capsulorhexis technique featuring a new maneuver for the removal of subcortical fluid in fluid-filled mature cataracts to avoid high intralenticular pressure.

Methods

This prospective interventional study included 33 eyes with mature cataracts and evidence of subcapsular fluid spaces by slit lamp examination. For each patient, 20% mannitol was administered intravenously according to the bodyweight 1 h preoperatively. Under peribulbar anesthesia, a 2.2-mm main incision was made, and the anterior chamber was filled with a dispersive ophthalmic viscosurgical device. Using a bent-tip cystotome, a 2-mm curved incision was made in the center of the anterior capsule, which released subcortical fluid and was drained through compression of the posterior lip of the main incision using a spatula. Then, fine gentle milking in all quadrants around the puncture on the anterior lens capsule from the periphery toward the site of puncture using the blunt-edged spatula further assists drainage of subcortical fluid and breaks fine septa inside the lens to remove fluid from intralenticular fluid pocket collections.

Results

The study included 15 (45.5%) men and 18 (54.5%) women with a mean (standard deviation [SD]) of age of 63.2 (5.33) and 64.4 (6.21) years, respectively. The modified capsulorhexis technique was performed for 33 intumescent cataracts. Capsulorhexis was completed in all cases; capsulorhexis was easy in 31 (94%) eyes and difficult in 2 (6%) eyes. In the two difficult cases, radial extension occurred in one eye, and it was retrieved using the Little technique; the other case with radial tear was completed successfully using a retinal micro scissor from the other edge of the capsulorhexis until reaching an oval, continuous capsulorhexis.

Conclusions

This modified capsulorhexis technique with compression on the posterior lip of the main incision and capsule milking allowed for a safe, continuous curvilinear capsulorhexis. Further comparative studies are necessary to confirm our preliminary results.