White Cataract: Run-Away Capsulorhexis -- how to fix it during cataract surgery

If you've done surgery on a patient with a white cataract, you've probably experienced the dreaded Argentinian Flag Sign.

This happens because unlike most routine cataracts, the white intumescent cataract is fluid filled and has an increased intra-lenticular pressure. When the capsular bag is punctured to start the capsulorhexis, posterior pressure is exerted on anterior lens capsule and that causes it to tear uncontrollably. This fluid is from liquefaction of the lens cortex so remember that it exists both behind and in front of the cataract endo-nucleus. The way to prevent this is to keep the pressure in the anterior chamber higher than the intra-lenticular pressure. This is accomplished by having only small paracentesis-type incisions and highly inflating the anterior chamber with viscoelastic. We can then work through this small paracentesis using a cystotome/bent-needle or specialized micro-forceps. 

But this doesn't alway work. In some patients, particularly the young patients who develop a white cataract quickly over the course of a month or two from trauma, recent onset of diabetes, or idiopathic reasons. In these patients the pressure in the capsule is so high, that as soon as the first opening is made in the anterior lens capsule, despite having a high anterior chamber pressure, milky fluid will egress and the capsule will run out. This is what happened here.

When this occurs, I try to quickly get the capsule to tear inwards, but despite my best efforts, it radializes out toward the zonular attachment. Now what? Let's stabilize the capsule by tearing the other direction and completing at least a partial capsulorhexis -- and in this case, let's keep is small. The classic Argentinian Flag Sign shows radialization in two directions, 180 degrees apart. In this case we were able to prevent that and we have just the one radialized area. 

Once we remove the soft lens material from the capsular bag, we can enlarge the capsulorhexis to a normal size and then proceed with the remainder of the surgery.