Simple approach to prevent capsule tear-out during capsulorhexis creation in hypermature cataracts

Preventing the Argentinian flag sign and managing anterior capsular tears: A review

The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule.

[Femtosecond laser-assisted phacoemulsification of hypermature cataract in patients with lens subluxation]

Studying the modern capabilities of femtosecond laser in the treatment of complicated cataracts is a topical problem in cataract surgery.

PURPOSE

To develop a technique for femtosecond laser-assisted phacoemulsification of hypermature cataract in patients with degree I-II lens subluxation.

MATERIAL AND METHODS

Phacoemulsification of hypermature cataract with comorbid lens subluxation was performed in 78 patients (78 eyes) divided into two groups. In the 1st group (45 eyes), capsulorhexis was performed using a femtosecond laser. Patients of the 2nd group (33 eyes) underwent manual capsulorhexis. The study assessed the possible frequency of using modern methods of capsular bag fixation and complete all-in-the-bag intraocular lens (IOL) implantation, as well as the number of various types of intraoperative capsular bag ruptures.

RESULTS

In all patients of the 1st group, capsulorhexis of the correct round shape and the required diameter was achieved, allowing the use of modern methods of fixation and centering of the capsular bag. Insignificant tear of the edge of the capsulorhexis after IOL implantation was detected only in 1 (2.2%) patient. Vitreous prolapse was noted in 1 (2.2%) case. In the 2nd group, manual technique resulted in oval capsulorhexis with a smooth edge, allowing the use of modern methods of fixation of the capsular bag only in 7 (21.2%) cases. Vitreous prolapse was noted in 4 (12.1%) cases. The complete in-the-bag IOL implantation was possible in 44 (97.8%) cases in the 1st group and only in 7 (21.2%) in the 2nd group.

CONCLUSION

The use of femtosecond laser in patients with hypermature cataract and lens subluxation allows achieving capsulorhexis of ideally round shape with a smooth edge. This creates the necessary conditions for the use of modern methods of fixation of the capsular bag and provides the possibility of complete all-in-the-bag IOL implantation.

Achieving successful capsulorhexis in intumescent white mature cataracts to prevent Argentinian flag sign - A new multifaceted approach to meet the challenge

Purpose:

To present a case series of intumescent white cataract cases managed by a new surgical technique to attain a single stage Continuous Curvilinear Capsulorhexis (CCC).

Methods:

The series included 60 eyes of 60 patients with white cataract which underwent preoperative anterior chamber depth, lens thickness and ultrasonographic A-scan for intralenticular spikes. A partial size main port (~1.8mm) is created as the first entry into the anterior chamber (AC). A 30-gauge needle of insulin syringe entered through a limbal stab incision is used to decompress the anterior and posterior intralenticular compartments. Following which a standard size, one stage capsulorhexis was performed in a trypan blue stained capsule using microcapsulorhexis forceps entered through the partial sized trapezoidal main port. The main port was secondarily enlarged for phacoemulsification.

Results:

Based on the intraoperative findings, 43 eyes were categorized as Intumescent type-1 cataracts i.e., with presence of actual liquefied cortex aspirated using 30-gauge needle and 17 eyes as Intumescent type-2 cataracts, i.e., presence of swollen lens without any obvious liquefied cortex. Standard size, circular and centred CCC was achieved in 100% of the cases and no Argentinean flag sign was noted. Surgeon perceived raised intralenticular pressure in 41% of the cases in type-1 subset and 61% cases in type-2 subset (P-0.06). Posterior capsular plaque was observed in 22% of the cases, adherent cortex in 25% and anterior capsular plaque in 5% of the cases. At 6weeks follow up 92% patients had best corrected visual acuity of 20/40 or better.

Conclusion:

A multi-layered approach can help in attaining successful CCC in cases of white mature cataract with high intralenticular pressure.

[Results of hybrid (femtosecond laser-assisted) phacoemulsification of hypermature cataract in patients with lens subluxation]

Studying the use of femtosecond laser in patients with complicated cataracts remains a topical issue in phaco surgery.

PURPOSE

To comparatively analyze the results of using hybrid (femtosecond laser-assisted) phacoemulsification in hypermature cataract in patients with lens subluxation.

MATERIAL AND METHODS

The study included 78 patients (78 eyes) with hypermature cataract in combination with lens subluxation of I-II degree. In the 1^st group (45 eyes) capsulorhexis was performed using a femtosecond laser. In the 2^nd group (33 eyes) manual capsulorhexis was performed.

RESULTS

On the first day after surgery, best corrected visual acuity of 0.8-1.0 was obtained in 57.8% of cases in the 1^st group and 33.3% in the 2^nd group. Transient corneal edema during the first 1-3 days was noted in 4.4% of cases in the 1^st group and in 15.2% - in the 2^nd group of patients. Pachymetry in the center of the cornea showed an increase in its thickness on the 1^st day after surgery from 0.564±0.027 mm to 0.591±0.033 mm in the 1^st group and from 0.561±0.023 mm to 0.637±0.043 mm (p<0.05) in the 2^nd group of patients. The loss of corneal endothelial cells amounted to 10.9±1.8% in the 1^st group and 17.4±2.9% in the 2^nd group (p<0.05). Macular edema with decreased visual acuity confirmed by OCT was detected in the 1^st group of patients in 2.2% of cases, in the 2^nd group - in 9.1% of cases. With a follow-up period of up to 3 years, IOL optics decentration by more than 1 mm was detected in 2.2% of cases in the 1^st group of patients and in 12.1% of cases in the 2^nd group.

CONCLUSION

Femtosecond laser-assisted capsulorhexis significantly improves the results of surgery in patients with hypermature cataract combined with lens subluxation.

Closed-Chamber Anterior Capsulorhexis Under Air Tamponade In White Cataract

Purpose

To evaluate the efficacy and safety of a closed-chamber air bubble capsulotomy technique to prevent the Argentinean flag sign (AFS) in patients with white and intumescent cataracts.

Setting

Sohag University, Faculty of Medicine, Ophthalmology Department, Sohag, Egypt.

Design

Prospective interventional noncomparative case series.

Methods

Eighty-two eyes of 80 patients with white and intumescent cataracts were included. Eyes with any ocular pathology other than cataract or eyes subjected to previous intraocular surgery were excluded. Needle capsulorhexis was performed under a large air bubble tamponade without capsular staining. Efficacy of the technique was assessed intraoperatively by successful completion of capsulorhexis. Safety of the technique was assessed by the occurrence of intraoperative or postoperative complications.

Results

Complete capsulorhexis by the closed-chamber air bubble technique was successful in 75 eyes (91.5%), while capsulorhexis extension occurred in seven eyes. In four eyes with extension, the procedure was shifted to the standard technique of CCC (circular curvilinear capsulorhexis), using a viscoelastic device. A shift to extracapsular cataract extraction (ECCE) surgery occurred in the remaining three eyes, as the extension was so far-gone. No intraoperative or postoperative complications were observed.

Conclusion

The closed anterior chamber air bubble technique for capsulorhexis is a novel, safe, and effective technique to prevent AFS in white and intumescent cataracts. It is also time-saving and cost-effective, with less likelihood of capsulorhexis extension. The technique is considered a valuable addition to previously described techniques.

A multipronged approach to prevent Argentinian flag sign in intumescent cataracts

In this communication, we describe a technique for creation of a single stage, adequately sized capsulorrhexis in intumescent cataracts by depressurizing the anterior and posterior intralenticular compartments in a nonleaky anterior chamber (AC) to prevent capsulorrhexis extension and Argentina flag sign. Initially, an incomplete main-port incision is made by the partial entry of a 2.2-mm keratome. A cohesive dispersive ophthalmic viscosurgical device (OVD) is injected into AC. Standard side-port incisions are made, followed by anterior capsular staining. The fluid cortex in anterior intralenticular compartment is aspirated by puncturing anterior capsule in the center using a 30-gauge needle entered through a separate limbal stab incision. The nucleus edge is gently tipped posteriorly with the needle tip to release the fluid from posterior intralenticular compartment also and as much fluid aspirated as possible. OVD is again injected and capsulorrhexis is performed in a single stage using micro-capsulorrhexis forceps.

[Morphological and clinical aspects of anterior capsulotomy in femtosecond laser-assisted cataract surgery]

The review covers morphological and clinical aspects of femtosecond laser-assisted anterior capsulotomy in cataract surgery. Literature data suggests that femtosecond laser-assisted capsulotomy is more accurate in size, shape, and centration than manual. Femtosecond laser-assisted anterior capsulotomy improves the accuracy of IOL positioning within the capsular bag.