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Intralenticular pressure in intumescent cataracts
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 An intumescent cataract with increased intralenticular pressure. |
With intumescent cataracts, there is swelling of the lens material with a relatively rapid decline in visual function. In addition, the intralenticular pressure rises, and this is what creates the challenge in cataract surgery.
When performing the capsulorrhexis, trypan blue dye is used to stain the anterior lens capsule to facilitate visualization. If we allow the anterior chamber pressure to be lower than the intralenticular pressure, then upon attempted creation of the capsulorrhexis, there is a rapid radialization resulting in the so-called Argentinian flag sign (three stripes: blue capsule, white cataract and blue capsule).
To prevent this occurrence, it is important to always keep the pressure of the anterior chamber higher than the intralenticular pressure. This can be accomplished by raising the anterior chamber pressure or lowering the intralenticular pressure.
To raise the anterior chamber pressure, make a paracentesis, and after staining the capsule with trypan blue dye, fill the anterior chamber with a very cohesive viscoelastic. This will keep the anterior chamber pressure quite high, and because there is just the single paracentesis, the viscoelastic is not likely to leak from the eye. Now, 25-gauge forceps can be used via the paracentesis to make the capsulorrhexis, with care taken to re-inflate the anterior chamber as needed. This is my preferred technique.
Alternatively, some surgeons like to insert a 27-gauge needle on a syringe into the lens and then aspirate in order to decompress it and lower the intralenticular pressure. The phaco probe can even be used to punch a single round hole, which tends not to radialize because it is a complete circle, in the center of the anterior lens capsule. The milky lens fluids will then leak out into the anterior chamber as the intralenticular pressure drops.
Keeping in mind the balance between the anterior chamber pressure and the intralenticular pressure can help to ensure a successful surgery in eyes with intumescent cataracts.
See Dr. Devgan share more expert insight live at OSN New York 2010, to be held November 19-21, 2010 at the Sheraton New York Hotel & Towers. Learn more at OSNNY.com.