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The challenge of the capsulorrhexis with a white cataract
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The white intumescent cataract poses a challenge during capsulorrhexis creation because the intralenticular pressure increases as the lens cortex liquefies. In a routine cataract, the lens material is solid and the pressure within the capsular bag is low — lower than the pressure in the anterior chamber, so capsulorrhexis creation is straightforward.
With the white intumescent cataract, the liquefied cortex increases the intracapsular pressure and forces the capsular bag to rip uncontrollably once it is opened. With the capsule stained with trypan blue dye, this uncontrolled radialization of the capsule toward the zonules gives the appearance of the Argentinian flag, which is why this complication is often referred to as the Argentinian flag sign.
White intumescent cataract.
The way to avoid the Argentinian flag sign and capsule radialization is to keep the anterior chamber pressure higher than the intralenticular pressure during capsulorrhexis creation. Make just one small paracentesis and stain the capsule with trypan blue dye.
Now fill the anterior chamber with a cohesive viscoelastic until the IOP is high (40 mm Hg or so). Now the capsulorrhexis is made only via this small paracentesis using a cystotome needle or small 25-gauge microforceps. Once the rhexis has started, gently rock the nucleus to release any intumescent fluid that may have been trapped between the posterior capsule and lens nucleus.
With this technique you can complete a round capsulorrhexis in the majority of these white intumescent cataracts. You could also use a femtosecond laser to make the capsulorrhexis because it would be made at once with the anterior chamber pressurized with the suction ring.