PUBLICATION EXCLUSIVE: Equalize pressure gradient to maintain control during removal of intumescent cataract

There are many challenges associated with phacoemulsification of intumescent white cataracts: The opaque lens material blocks the red reflex and hinders visualization of the capsule, the nuclear material may be quite dense, and there is a tendency for the capsulorrhexis to become errant, which can result in complications such as vitreous prolapse.Using trypan blue dye, we can stain the anterior lens capsule to aid in visualization during capsulorrhexis creation. With phaco power modulations and variants of the phaco chop technique, we can safely remove even dense nuclei while limiting the ultrasonic energy used. But perhaps the biggest challenge is avoiding the runout of the capsulorrhexis, which can result in the “Argentinian flag sign.” This syndrome gets its name from the appearance of the capsule and cataract after the capsulorrhexis has been lost and three stripes appear: a middle stripe of white cataract flanked by the remainder of the anterior capsule, which has been stained blue.