Argentinean flag sign is most common complication for intumescent cataracts

To prevent this complication, choose the right viscoelastic and avoid tension on the lens.

Argentinean flag sign is the name I have chosen to describe the most common complication when performing capsulorrhexis in intumescent cataracts stained with trypan blue.

When a spontaneous tear in the capsule extends into the periphery, the appearance of the stained capsule beside the white cataract mimics the blue-white-blue arrangement of the Argentinian flag. This complication inspired me to create a video, which received awards at the 2000 American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgeons video competitions.

As I say in the video, “It is not the case I dislike my flag, but I’d rather not remember it in that way.” Therefore, it is important to avoid this complication.

Steps to avoid it

To avoid this complication, first of all, choose the correct viscoelastic agent. Sometimes we use hydroxymethylcellulose in routine cases, but with white cataracts we should maintain a deep anterior chamber during the capsulorrhexis process, because anterior displacement of the irido-lens diaphragm produces centrifugal forces that lead the tear toward the periphery.

Thus it is mandatory to use highly cohesive viscoelastic agents.

A second issue is to avoid creating outer and inner tension on the lens. External tension can be caused by the speculum, especially in narrow orbits. Another cause may be excess in parabulbar anesthesia. In such cases, the main reason is the high tension on the lens capsule due to hyperhydration of lens fibers. Sometimes I prefer to decompress the lens with a small puncture, allowing the milky liquid to escape from the lens.

Despite being aware of all these issues, sometimes the Argentinean flag sign may be raised.

Management

Whenever the tear leads toward the periphery, we should begin a new tear to correct it. But in this case, we have two tears — one anterior to the other. Therefore, we will have to finish the rhexis in a can-opener style or re-grasp the tear after creating a new one. This can be done with a bent needle, forceps or micro-scissors.

The next step is nucleus management. It is a must to avoid perpendicular forces against the capsular tear because of the high risk of extending the tear toward the posterior capsule. The nucleus can be cracked or divided into two heminuclei with a soft vertical chop or with a sculpting technique. Phacoemulsification should be done in the iris plane. Fortunately, these cataracts are not too hard.

IOL implantation may be done in the bag, taking care not to enlarge the existing tear and placing the haptics perpendicular to it.

Remember, if you are an Argentine surgeon and the Argentinean sign comes up, try to suppress your patriotic feelings and quickly solve this complication.

With hydroxymethylcellulose viscoelastic, anterior displacement of the iris-lens diaphragm produces centrifugal forces that lead the tear toward the periphery (top). In cases of white cataract, the anterior chamber must be supported by highly cohesive viscoelastic agents (bottom).
During the execution of the rhexis, a tear into the periphery is noted.	Capsulorrhexis is begun on a white stained with trypan blue for visibility.
The Argentinian flag.	When the tear extends in both directions, its appearance mimics the Argentinian flag.
Nucleus management is a must to avoid perpendicular forces against the capsular tear.	IOL implantation may be done in the bag.

For Your Information:

• Daniel Mario Perrone, MD, can be reached at Centro de Ojos Quilmes, Humberto Primo 298 Quilmes (1878), Buenos Aires, Argentina; (54) 11-4254 9388; fax: (54) 11-4224 4844; e-mail: cdoquilm@ciudad.com.ar. Dr. Perrone has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.