Eyeworld

EW FEATURE 58 by Faith A. Hayden EyeWorld Staff Writer Managing the rock hard cataract Pearls of wisdom for a successful surgery R emoving a hypermature cataract is not an every- day occurrence at oph- thalmology practices in the United States. But these extreme cases do happen with some frequency stateside, particu- larly in rural areas. Without proper precautions the surgery can head south at an alarming rate, with a sudden jagged strip of white extend- ing end-to-end across the blue- stained capsule. This complication, known as the Argentinian Flag Sign (AFS), is the most common compli- cation for intumescent cataracts and one of the more dangerous. How do you manage a white cataract successfully? Can the Argen- tinian Flag Sign be avoided alto- gether? EyeWorld spoke with a number of cataract surgeons who answered those questions and pro- vided surgical pearls to keep fellow physicians out of trouble. Staining the capsule Trypan blue overwhelmingly is the staining dye of choice among doc- tors interviewed, with one physician calling it "a godsend." "We used to have to use things like indocyanine green, which just barely stained the capsule," said Herbert Ingraham, M.D., chairman, ophthalmology department, Geisinger Health System, Danville, Pa. "But even if you do a lousy job staining, with trypan blue you al- most always do just fine." There are two ways to stain the capsule, either under an air bubble or under viscoelastic. Each option has varying appropriateness and de- grees of difficulty. For Samuel Masket, M.D., clinical professor of ophthalmology, Jules Stein Eye Insti- tute, David Geffen School of Medi- cine, University of California, Los Angeles, his staining technique of choice depends on the nature of the case and what viscoelastic he's using. For instance, if he's working with an agent that is strictly cohe- sive, say Healon GV or Healon5 (sodium hyaluronate, Abbott Medical Optics, Santa Ana, Calif.), he stains under viscoelastic. "However, if it's the dispersive type of visco agent, I prefer to do it under a bubble," Dr. Masket said. "The dispersive agent adheres to the tissue, and if it retains any of the trypan blue, visibility is reduced." Dr. Ingraham also uses the air bubble method, acknowledging that although it provides the deepest stain, the technique may be prob- lematic for surgeons unfamiliar with the process. One trick Dr. Masket suggested to keep the bubble intact is to place a small amount of vis- coelastic just inside the incision im- mediately after making the bubble. "What this does is act as a sealant," he said. "A tiny patch of visco agent in and at the edge of the incision will tend to prevent air from escaping." If a surgeon isn't comfortable with the air bubble approach, insert- ing trypan blue over viscoelastic works, too. The stain won't be as deep, but the technique may be eas- ier. "Put your viscoelastic in, and don't fill it as full as you normally would," Dr. Ingraham said. "Leave the eye a little bit soft, and then put the trypan blue in and just paint it onto the capsule." One pearl Lisa Arbisser, M.D., adjunct clinical associate professor, John A. Moran Eye Center, Univer- sity of Utah, Salt Lake City, gives try- pan users is the dye can be painted on after opening the capsule because it doesn't stain the cortex. "For example, if you're doing a capsulorhexis and it starts to go to the wrong direction, you can paint a little bit of trypan right over that area," she explained. "You'll be able to see it more clearly, and frankly, the fact that it reduces elasticity probably helps in recovering the rhexis." Preventing and managing the Argentinian Flag Sign "The Argentinian Flag Sign does not happen easily," said Dr. Arbisser. "It doesn't have to happen to people, and it doesn't happen automatically. It happens because we allow the pressure between the anterior cham- ber and the posterior chamber to not be stable. We can't always con- trol every environment perfectly every time, but we can come close if we know what we're doing and why." Dr. Arbisser has a number of tips on how to prevent AFS. For exam- ple, avoid operating on a traumatic intumescent cataract if there's no risk of phacomorphic glaucoma, leaking, or uveitis. "If you wait a little bit, [the cataract] will organize a little more in most cases and not be so intumes- cent and risky," she said. If Dr. Arbisser does have to oper- February 2011 Challenging cataract cases September 2011 AT A GLANCE • Capsule can be stained under air or viscoelastic • The Argentinian Flag Sign occurs because pressure between the anterior chamber and the posterior chamber is not stable • To avoid the Argentinian Flag Sign, start with a small rhexis • Some white cataract cases are too problematic for phaco. In those cases, manual small incision surgery is best An example of a white cataract Source: Gary Miller, C.R.A., O.C.T.-C.

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