OCT 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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92 EW International October 2013 Views from Asia-Pacific: Argentinian Flag Sign Soon Phaik Chee, MD Ke Yao, MD I n the "Tools & techniques" column of the February 2013 issue of EyeWorld, Christopher C. Teng, MD, described how he handles the Argentinian Flag Sign, which can cause cataract extraction to become extremely difficult and lead to many complications, including posterior capsule rupture, vitreous loss, retained nucleus, and endothelial damage due to prolonged surgery time. Dr. Teng uses phaco capsulotomy, "a technique in which the phacoemulsification tip is used to simultaneously create the initial tear in the anterior capsule and remove a portion of the intumescent lens, thereby debulking and relieving pressure from the lens and capsule, and preventing the Argentinian Flag Sign." In our sister publication, EyeWorld Asia-Pacific, Soon Phaik Chee, MD, Singapore, and Ke Yao, MD, China, shared their thoughts on the technique. Dr. Chee: Creating an intact continuous curvilinear capsulorhexis (CCC) for the intumescent cataract always poses a challenge for the cataract surgeon. This step is crucial for phacoemulsification especially when dealing with a dense nucleus. In eyes with shallow anterior chambers, the intumescent lens may present as phacomorphic glaucoma, complicating the surgery further. There are various ways of avoiding the Argentinian Flag Sign. Dr. Teng describes "phaco capsulotomy," which I have had no personal experience with. I am reluctant to use this technique for fear of creating a leading edge, which may extend in an uncontrolled fashion during the initial maneuver. If the phaco tip becomes occluded, resulting in impaling of the nucleus, further aspiration of the liquefied cortex will cease, allowing the tear to propagate. I routinely use the needle aspiration method, which has rarely failed in my hands. Here are some tips for a successful outcome: 1. Run intravenous mannitol to shrink the vitreous and swollen lens a half hour prior to surgery even in the absence of raised intraocular pressure. 2. Avoid speculums that exert pressure on the globe. 3. Have a low threshold for giving regional anesthetic block in an uncooperative patient. 4. Always use capsular dye to ensure visibility of the anterior capsule. Apply the dye directly onto the capsule under viscoelastic to avoid staining of the endothelium of a swollen cornea. 5. Fill the eye with Healon5 (Abbott Medical Optics, Santa Ana, Calif.) in the presence of significant positive pressure until the anterior capsule is flattened. 6. Enter the eye only partially with the keratome in order to keep the main incision small, thus minimizing viscoelastic loss and maintaining a deep anterior chamber. Enlarge the incision once lens decompression is successful. 7. Perform trans pars plana 23-gauge limited anterior vitrectomy to decompress the eye if the anterior chamber is still extremely shallow and the anterior capsule is bulging. 8. While holding a 1-cc syringe fitted with a 27-gauge needle bevel up, simultaneously puncture the anterior capsule and aspirate liquefied cortex, pressing down on the nucleus. Rotate the bevel sideways without extending the breach in the anterior. Argentinian Flag Sign. Arrow indicates tear of the anterior capsule, which extends to the periphery Source: Christopher C. Teng, MD Apply posterior pressure on the nucleus repeatedly in order to displace the liquefied cortex anteriorly and aspirate continuously. 9. Fill the anterior chamber with retentive viscoelastic and complete the CCC. Use intraocular capsulorhexis forceps if the lens is still swollen. Dr. Yao: When a highly intumescent, bulging white lens is seen under the surgical microscope, the surgeon will usually pause and hope that a rapid tear of the anterior capsule to the lens equator will not happen. White and intumescent cataracts are common in China, especially in the remote countryside. The incidence of white cataracts is 5 to 10% in our eye center, Second Affiliated Hospital of Zhejiang University. Fortunately, the Argentinian Flag Sign occurs in only 10% or less of these cases. It is a challenge for the cataract surgeon to perform the remaining surgery. When I see a white and intumescent cataract, it is necessary to evaluate the possibility of the Argentinian Flag Sign before capsulorhexis. For the white cataract without a liquefied cortex, capsulorhexis would be performed directly after the capsular staining and OVD injection. If the injection of OVD can change the shape of the lens surface due to the liquefied cortex, there is a risk of the Argentinian Flag Sign developing. In these cases, I would inject a highly cohesive OVD from the anterior chamber central and flatten the central anterior capsule as much as possible. Adequate anterior chamber formation facilitates the following steps although it requires more OVD. A 27-gauge needle on a syringe is introduced into the center of the anterior capsule with a downward angle, and the liquefied cortex is aspirated simultaneously to depressurize the underlying nucleus, which is definitely an effective method to prevent the Argentinian Flag Sign. As long as the anterior capsule does not tear and extend to the periphery when punctured, the risk will be reduced greatly with the aspiration of the liquefied cortex. Additionally, once enough liquefied cortex is aspirated, OVD can be used to pressurize the anterior capsule, followed by capsulorhexis. A leaflet of the capsule should be grasped and torn concentrically with forceps during the capsulorhexis. Any outward force can easily tear the capsule to the lens equator because of the brittle anterior capsule. I have not performed the phaco capsulotomy presented by Dr. Teng for dealing with white and intumescent cataracts. I think it is a good method worth being popularized. Regardless of which method you use, if the Argentinian Flag Sign does occur, be cautious in deciding whether to continue phacoemulsification. With a hard and large nucleus, switching to ECCE and circling out the nucleus by widening the incision can avoid many serious complications such as rupture of the posterior capsule and nucleus dislocation into the vitreous. EW Editors' note: Dr. Chee has financial interests with Bausch + Lomb/ Technolas Perfect Vision (Rochester, N.Y./Singapore) and Hoya Surgical Optics (Chino Hills, Calif.). Dr. Yao has no financial interests related to this article. Contact information Chee: chee.soon.phaik@snec.com.sg Yao: xlren@zju.edu.cn

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