EyeWorld Asia-Pacific March 2013 Issue

23 EWAP CATARACT/IOL March 2013 CHEE Soon Phaik, MD Senior Consultant and Head, Cataract Subspecialty Service and Ocular Inflammation & Immunology, Singapore National Eye Centre Associate Professor, Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, and Duke-National University of Singapore Post Graduate Medical School, Singapore, Singapore Eye Research Institute 11 Third Hospital Avenue, Singapore 168751 Tel. no. +65-62277255 Fax no. +65-62277290 chee.soon.phaik@snec.com.sg C reating 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 chamber, the intumescent lens may present as phacomorphic glaucoma, complicating the surgery further. There are various ways of avoiding the Argentinian Flag Sign. This article describes the “phaco capsulotomy”, which I have had no personal experience with. I am reluctant to use this technique for fear of creating a leading edge (as seen in Figure 2B) 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 squeezing 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 Healon 5 (Abbott Medical Optics, Santa Ana, Calif., USA) 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. Ballot the nucleus and continue aspiration as liquefied cortex from behind the nucleus is displaced anteriorly. 9. Fill the anterior chamber with retentive viscoelastic and complete the CCC. Use intraocular capsulorhexis forceps if the lens is still swollen. Editors’ note: Prof. Chee is a consultant for Bausch + Lomb/Technolas Perfect Vision (Rochester, NY, USA/Munich, Germany), and Hoya Surgical Optics Pte. Ltd. (Chino Hills, Calif., USA), but has no financial interests in the content of her comments.2007;33:47-52. Views from Asia-Pacific YAO Ke, MD Professor, Eye Center, Second Affiliated Hospital, College of Medicine, Zhejiang University 88 Jiefang Road, Hangzhou 310009, Zhejiang Province, China Tel. no. +86-571-87783897 Fax no. +86-571-87783897 xlren@zju.edu.cn W hen 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 would 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 kind of challenge for the cataract surgeon to perform the remaining surgery. When I meet 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 flat the central anterior capsule as much as possible. Adequate anterior chamber formation facilitates the following steps although it requires more OVD. Then, a 27-guage 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 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. According to the introduction, I think it is a nice method worth being popularized. The point of my comments is that regardless of which method you use, if the Argentinian Flag Sign does occur, be cautious in deciding whether to continue phacoemulsification. Meeting 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. Editors’ note: Prof. Yao has no financial interests related to his comments.