EyeWorld Asia-Pacific March 2013 Issue

22 EWAP CATARACT/IOL March 2013 Preventing the Argentinian Flag Sign: Phaco capsulotomy by Christopher C. Teng, MD T he Argentinian Flag Sign occurs during capsulorhexis construction. Due to the overbearing pressure of the cataract, the anterior capsule tears and extends to the periphery. Once this occurs, the remainder of the cataract extraction can become extremely difficult and can lead to many complications, such as posterior capsule rupture, vitreous loss, retained nucleus, and endothelial damage due to prolonged surgery time. Phaco capsulotomy is 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. Introduction White cataracts and intumescent cataracts are challenging cases for most surgeons. In these eyes, during capsulorhexis creation, the pressure created by the hyperhydration of lens fibers can cause spontaneous tears in the capsulorhexis that extend to the periphery. When this occurs, the appearance of the stained blue anterior capsule beside the white cataract mimics the blue-white-blue pattern of the Argentinian flag and was named the Argentinian Flag Sign (Figure 1). Daniel Mario Perrone, MD, coined the term, and his video won awards at the 2000 American Society of Cataract & Refractive Surgery and the European Society of Cataract & Refractive Surgeons annual meetings. One method for preventing the Argentinian Flag Sign is by introducing a 27-gauge needle on a syringe into an intact anterior capsule. The needle is used to aspirate the liquefied cortex, thereby depressurizing the nucleus, which facilitates a controlled capsulorhexis. 1 Additionally, a highly cohesive ophthalmic viscosurgical device (OVD) can be used to pressurize the anterior chamber against the pressure of the intumescent lens, which can facilitate continuous curvilinear capsulorhexis (CCC) completion.2 Alternatively, a CCC can be created using a two- stage technique, which can help prevent unexpected radial tears.3 The phaco capsulotomy technique, which likely first originated in India, introduces the phacoemulsification tip through the center of an intact anterior capsule and aspirates a portion of the lens. This simultaneously creates the initial anterior capsule puncture and removes some of the liquefied cortex and nucleus. Phaco capsulotomy debulks and depressurizes the entire lens/ capsule apparatus, and removes the impetus for the capsule to tear outward. Once enough of the cortex is aspirated, OVD is injected and a leaflet of the capsule can be grasped with a forceps, and the capsulorhexis can be completed without complication. Technique The initial steps are identical to a cataract extraction in which capsular stain is used. This includes creating a paracentesis, using a capsular stain, injecting highly cohesive and/or dispersive OVD, and creating a main wound. After the main wound is created, the phacoemulsification tip is introduced into the eye. The handpiece should not be irrigating upon entry, as there is OVD present in the anterior chamber that maintains anterior chamber form. The bevel of the tip should be positioned facing up, as this best facilitates removal of liquefied cortex and underlying nucleus. Next, the phacoemulsification tip should be directed at a downward angle and situated over the center of the anterior capsule. The settings on a torsional phacoemulsification machine should be in the sculpting mode, with no phacoemulsification power but high phaco handpiece Figure 1. Argentinian Flag Sign. Arrow indicates tear of the anterior capsule, which extends to the periphery. Figure 2B. Ophthalmic viscosurgical device injected into the anterior chamber, with good visualization of the capsular tear Figure 2C. Completion of a continuous curvilinear capsulorhexis Source (all): Christopher C. Teng, MD Figure 2A. Phaco tip puncturing an intact anterior capsule and aspirating and debulk- ing the nucleus continued on page 24