YO Pick: Preventing the Argentinean flag, Brazilian style

White cataracts are one of the most challenging types of cataracts we encounter as eye surgeons, as they cause poor visibility of the anterior lens capsule and a tendency for radialization of the capsulorhexis. These tendencies have been shown to increase the risk of posterior capsular rupture, vitreous loss, and lens drop.  In its most extreme form, white cataracts can develop an "Argentinian flag" configuration, in which a Trypan-blue stained capsule splits down the middle immediately after puncturing it, taking on the appearance of the blue and white Argentinian flag. 

This article by Carlos G. Figueiredo, MD, and colleagues offers an explanation of the mechanisms underlying these tendencies in white cataracts, and describes specific surgical maneuvers to overcome them, including their own Brazilian technique, which they discuss in detail. 

This review is useful to all cataract surgeons who perform surgery on white cataracts, but it's particularly helpful for beginning surgeons and residents, who encounter this type of challenging cataract early in training. The principles described in this article will help identify risks associated with this type of cataract, and the techniques described and demonstrated in accompanying supplemental video can be used to address these risks safely and effectively.  

Fluid-filled white cataracts are particularly treacherous because of the two pressurized pockets of liquefied cortex that form above and below the nucleus. The anterior fluid-pocket can obscure visualization of the anterior lens capsule, while the posterior pocket can push the nucleus up and cause radialization of the capsulorhexis tear.

The authors describe a technique designed to relieve these pressure pockets while keeping the anterior chamber pressurized. In their technique, the anterior pocket is removed by blowing liquefied cortex out through the main wound using a dispersive ophthalmic viscosurgical device (OVD). The OVD cannula is placed through the main incision and the tip is passed beyond the punctured anterior capsule.  Injection of OVD pushes the cloudy cortex out the main wound without causing any shallowing of the anterior chamber.

The posterior pocket of liquefied cortex is removed using bimanual irrigation/aspiration through two side-port incisions. The key principle underlying both techniques is depressurizing the liquefied cortex without causing any decrease in anterior chamber pressure. This avoids forward movement by the lens and its resultant radializing forces. 

The strength of this article lies in the helpful description and diagrams demonstrating the forces at work in fluid-filled white cataracts. The authors' techniques are clearly described and can be utilized in most settings where phacoemulsification is performed. The authors also included a narrated surgical video that effectively demonstrates their techniques in action.