Pressurized capsular bag of intumescent white cataract can be challenging
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In most cataract cases, there is no pressurization of the capsular bag because the cataract is solid.
When we open the anterior capsule to create the capsulorrhexis, there is no intralenticular pressure pushing forward, and we can proceed normally. However, in some advanced cataracts, the lens cortex can become liquefied as it becomes opaque and white. These intumescent white cataracts have a capsular bag that is fluid filled and pressurized so that there is a tendency to have an uncontrolled run-out of the capsulorrhexis.
We have all experienced cases in which the dreaded “Argentinian flag” sign develops instantly as the anterior lens capsule splits uncontrollably. The anterior capsule, stained with trypan blue dye, has now split, and it resembles that flag with the blue-white-blue pattern (Figure 1). Just watching a video of this makes me uncomfortable, and when it happens during our surgeries, it is even worse. This irregular capsular opening makes the risk of complications such as vitreous loss, retained lens material and IOL instability higher.
Source: Uday Devgan, MD
When the capsular bag is punctured to start the capsulorrhexis, posterior pressure is exerted on the anterior lens capsule, which causes it to tear uncontrollably. This fluid is from liquefaction of the lens cortex, so remember that it exists both behind and in front of the cataract endonucleus. One way to prevent this is to keep the pressure in the anterior chamber higher than the intralenticular pressure. This can be accomplished by having only small paracentesis-type incisions and highly inflating the anterior chamber with viscoelastic. We can then work through this small paracentesis using a cystotome/bent needle or specialized microforceps. We can also try to perform needle aspiration of the liquefied cortex, but again, it is not always successful.
But these techniques do not always work, particularly in young patients who develop a white cataract quickly over the course of a month or two from trauma, recent onset of diabetes or idiopathic reasons. In these patients, the pressure in the capsule is so high that as soon as the first opening is made in the anterior lens capsule, despite having a high anterior chamber pressure, milky fluid will rapidly egress, and the capsule will run out. We have shown previous videos of using a femtosecond laser to try to solve this conundrum, but again, it can leave capsular adhesions and tags because the laser is relatively slow. Also, as the liquefied lens cortex starts to egress into the anterior chamber, it blocks the transmission of the laser energy. Even phaco puncture, in which the phaco probe is buzzed into the anterior lens capsule, has been tried but with variable results. Certainly, there has to be a better way.
The Zepto precision pulse capsulotomy system (Centricity Vision) uses a collapsible nitinol ring that is centered by the surgeon on the anterior lens capsule. It goes through incisions as small as 2 mm, and it uses suction to fixate the anterior lens capsule as the brief pulse of energy is delivered to create the capsular opening (Figure 2). After using the Zepto device extensively, there is no doubt that it is the ideal device for intumescent cataracts. The device makes a 5.2-mm opening in the anterior lens capsule in just 4 milliseconds using a brief burst of energy. This creates a centered, strong and reliable capsulotomy and prevents the Argentinian flag sign from ever occurring.
Once the capsular opening has been made, the rest of the cataract surgery is simplified because the risk for capsular run-out has been eliminated. The capsular opening is strong and perfectly round, so it overlaps the optic to provide secure IOL fixation and a reliable effective lens position for better refractive outcomes (Figure 3). The next time that you encounter a challenging case in which capsulorrhexis creation is difficult, such as intumescent white cataracts, I encourage you to try the Zepto precision pulse system. It will make the surgery less stressful for you and provide better outcomes for your patients.
This video shows my pearls for success and why it is the gold standard for intumescent white cataracts. The full video is at https://cataractcoach.com/2022/07/08/1523-zepto-for-intumescent-cataracts/.
- For more information:
- Uday Devgan, MD, is in private practice at Devgan Eye Surgery and partner at Specialty Surgical Center in Beverly Hills. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.CataractCoach.com.
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