White Cataract: Run-Away Capsulorhexis. Help!

If you’ve done surgery on a patient with a white cataract, you’ve probably experienced the dreaded Argentinian Flag Sign. (Full video below)

Argentinian flag signThis happens because unlike most routine cataracts, the white intumescent cataract is fluid filled and has an increased intra-lenticular pressure. When the capsular bag is punctured to start the capsulorhexis, posterior pressure is exerted on anterior lens capsule and that 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 endo-nucleus. The way to prevent this is to keep the pressure in the anterior chamber higher than the intra-lenticular pressure. This is 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 micro-forceps.

But this doesn’t alway work. In some patients, particularly the 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 egress and the capsule will run out. This is what happened here.

DWC milk comes out

When this occurs, I try to quickly get the capsule to tear inwards, but despite my best efforts, it radializes out toward the zonular attachment. Now what? Let’s stabilize the capsule by tearing the other direction and completing at least a partial capsulorhexis — and in this case, let’s keep is small. The classic Argentinian Flag Sign shows radialization in two directions, 180 degrees apart. In this case we were able to prevent that and we have just the one radialized area.

Once we remove the soft lens material from the capsular bag, we can enlarge the capsulorhexis to a normal size and then proceed with the remainder of the surgery.

What are some of the options for dealing with these cases?

  • keep the AC pressure higher than the intra-lenticular pressure and start the capsulorhexis through a small paracentesis incision
  • use a needle and syringe to puncture the anterior lens capsule and aspirate the intumescent fluid to decompress the lens capsular bag
  • use the phaco probe to punch a small opening in the central anterior lens capsule to decompress the bag with hope that the round opening will not radialize
  • use the double-capsulorhexis technique to first make a small capsular opening, then decompress the fluid, then make a larger opening (that’s tomorrow’s video)
  • use a femtosecond laser to create a capsular opening in just a second or two before making any incisions into the eye (that’s the video for the day after tomorrow)
  • use a cystotome to make a can-opener type capsulotomy which has so many areas of slight radialization that the forces are spread evenly and the risk of posterior capsular split is low.

Check out the video for the full explanation:

All content including text, pictures, videos is ©2018 Uday Devgan MD. All rights reserved.


  1. thanks a lot sir for such beautifully managed case.in last OT I’ve also same case with same age group,in which rhexis radiallized on to the posterior capsule.i’ve left him aphakic with ant vitrectomy done,now i am planning for secondary iol implantation after 3 weeks.sir,please tell me what are the options gor such patients and which will be best for his age group.thanks a lot

    1. For a young patient, we have to think of what is best for the very long term — 50 years. This means a sulcus IOL (3-piece style) if there is sufficient capsular support. If there is not, then I suggest doing a scleral sutured IOL such as the Akreos + GoreTex solution that is very stable and will last for decades. I will be posting an article and video about this in the next two weeks or so.

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