White Cataracts: Can you pass the Quiz?

Only a true cataract expert will pass this 2 minute test!

The past five articles and videos have all been dealing with White Cataracts, one of the trickiest situations that we encounter during cataract surgery. Now is the time to prove to yourself that you’ve learned a lot.

The following quiz is purely for your own benefit. And, of course, the benefit of your patients. Test yourself — the correct answer will follow after every question.

white cat quiz 1

Question 1: This white cataract is as a result of prior penetrating trauma in a 27 year old man who was working at a construction site without eye protection. The corneal laceration was closed and then one month later the patient developed the following clinical appearance. Which is the most likely true statement:

  1. This is likely to be a very dense cataract with a tough posterior nuclear plate.
  2. Trypan blue dye would not be very useful in the case.
  3. The opaque lens material will be soft and easily aspirated.
  4. Making the capsulorhexis will be easy because the patient is young



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Answer 1: Correct answer is 3. The opaque lens material is soft and easily aspirated. Trypan blue dye certainly would help show the capsule, which in this case is likely already punctured or damaged. Making the capsulorhexis will not be easy. This lens will not be dense and there will be no fibrous, dense posterior nuclear plate.

white cat quiz 2

Question 2: This patient has a white cataract and Trypan blue dye has been used to stain the anterior lens capsule. Now viscoelastic is being placed into the anterior chamber to displace the blue dye. When this occurs there is a blue ring (green arrow in pic) that is noted on the anterior lens capsule. What is this from?

  1. The patient has pseudo-exfoliation and this is a mark from deposition of that PXF material on the anterior lens capsule.
  2. This surgeon used a femtosecond laser to create the capsular opening prior to making the first incision for surgery.
  3. That is just a reflection from the posterior surface of the cornea due to the microscope lights.
  4. The patient had prior trauma and when the iris was pushed up against the anterior lens capsule, it deposited a ring of pigment.



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Answer 2: Correct answer is 2. A femtosecond laser was used to create the anterior capsular opening before making the first external incision for cataract surgery. The Trypan blue dye stains the edge of the capsular opening very well so that when the viscoelastic is instilled and the dye removed, the stained edge is easily seen.

white cat quiz 3

Question 3: This 80 year old patient has a shallow anterior chamber, an axial length of 20.0 mm, and a white-to-white measurement of 10.5 mm. The anterior lens capsule was stained with Trypan blue dye and now a capsulorhexis is being created. Which is most likely?

  1. This capsulorhexis will radialize out to the periphery and the Argentinian Flag Sign will become evident very soon.
  2. The cataract will be dense and in order to split the posterior plate, the nucleus should be prolapsed into the anterior chamber using hydrodissection.
  3. This is a relatively soft cataract with fluffy white cortex material causing most of the opacity so the I/A probe should be sufficient for removal.
  4. This is too small of a capsulorhexis and it will cause challenges in removing this nucleus.



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Answer 3: Correct answer is 4. This capsulorhexis is just too small with approximately a 4 mm diameter. This will make removal of this dense nucleus quite difficult. This elderly patient has a dense cataract with a lot of nuclear sclerosis as well as a dense posterior plate. Surgeons can get tricked into creating a small capsulorhexis when the corneal diameter is small and the pupil dilation is not great.

white cat quiz 4

Question 4: This patient has an opaque, white cataract centrally, but the periphery of the lens appears relatively clear. Which statement is likely to be false in this case?

  1. The patient will have milky fluid escape from the initial capsular opening since this is an intumescent white cataract.
  2. The central nucleus will have more density and require more ultrasonic energy for removal compared to the peripheral nucleus.
  3. After using Trypan blue dye to stain the capsule and making a capsulorhexis, this case should proceed normally.
  4. This lens likely has a dense posterior plate which will make nucleus division more difficult.



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Answer 4: Statement 1 is most likely to be false. This patient has a relatively clear cortex, none of which has liquefied into intumesent fluid. Once the capsulorhexis is made, this case should proceed normally. It has moderate nuclear density and should not pose much of an issue to an experienced cataract surgeon.

white cat quiz 5

Question 5: This patient has a long-standing history of poor vision in this eye for at least 5 years and has resulted in significant exotropia in this eye. The anterior lens capsule is wrinkled and contracted, causing a gap between the iris and the lens. Ultrasound B-Scan of the posterior segment appears normal. Which of the following is least likely?

  1. There could be zonular weakness or loss which would cause instability of the cataract during phacoemulsification.
  2. This nucleus appears dense and a tough posterior nuclear plate is likely which would make nucleus removal more challenging.
  3. Making the capsulorhexis in this eye will be easy because the zonules are keeping the anterior lens capsule taught and flat.
  4. The long-standing exotropia may lead to diplopia in the post-op period, which may not resolve spontaneously.




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Answer 5: The least likely statement is 3. The capsulorhexis is not likely to be easy because the anterior lens capsule is fibrotic and not flat, also the zonules may be weak since there is now a gap between the iris and lens. This will not be an easy surgery and the potential for complications is high.

white cat quit 6

Question 6: This 22 year old patient presents to your clinic with the white cataract shown in the photo above. Which possible issues for this patient and his surgery do you expect?

  1. The patient appears to be aniridic since no iris is visible, even at the angle. These aniridic patients can have a host of other ocular issues.
  2. This cataract appears white with a slight blue hue, which, in addition to his young age, make an intumescent cataract with a soft lens more likely.
  3. The temporal aspect of the lens shows an irregular contour of the lens equator which may indicate zonular irregularities in that region.
  4. All of the above.



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Answer 6: Option 4 (All of the above) is the correct response. This aniridic patient will be a surgical challenge for even experienced cataract surgeons.

white cat quiz 7

Question 7: This 21 year old patient was in a car accident recently and was hit in the face by the airbag. She was sitting too close to the steering wheel and there was insufficient room for proper deployment of the airbag. The patient has a white cataract which has subluxed significantly and there is vitreous coming through the superior part of the pupil into the anterior chamber. With head movement, the lens is highly mobile and when she is reclined into a supine position, the cataract falls into the mid-vitreous. What is the best and safest surgical approach to this cataract?

  1. Pars plana vitrectomy and lensectomy, with placement of a suture fixated PC IOL
  2. Temporal corneal incision with use of the phaco probe to fish for the cataract in the vitreous cavity.
  3. Large incision manual extra-cap surgery using viscoelastic to push the vitreous back into the vitreous cavity.
  4. Couch the cataract and push it all the way into the vitreous cavity and then give the patient an aphakic contact lens.



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Answer 7: The best approach is option 1: pars plana vitrectomy and lensectomy with placement of a sutured PC IOL. Alternatively, an AC IOL could be placed but this patient is young and it may cause premature corneal endothelial cell loss since it would be in place for many decades. There are techniques using PC IOLs with 4 eyelets and Gore-Tex suture that provide excellent results and long term stability. This technique will be described in a future article and video. Do not ever fish in the vitreous cavity with the phaco probe because it will cause a giant retinal tear and more complications.

white cat quiz 8

Question 8: Bonus Question. This patient is 55 years old and had a prior full-thickness penetrating keratoplasty in the right eye done else where about 5 years ago due to damage from a corneal ulcer. There are still a few 10-0 nylon sutures in the cornea. The photo shows the maximum pupil dilation after three sets of tropicamide 1%, cyclopentolate 1%, and phenylephrine 10%. By history, the cataract started developing over the past 4 months which is around the time the patient was diagnosed with diabetes mellitus. The vision rapidly deteriorated in the past month to its current level of light perception with projection. The left eye is completely normal and sees 20/20. B-scan of the right eye reveals a normal posterior segment. The corneal endothelial cell count is 1030 cells/mm² in the right eye and 2800 cells/mm² in the left eye. Using the lowest K power in the center of the cornea and aiming for mild myopia of -1, it is determined that a +22.0 D IOL (at A constant of 119.2) would be best.

Describe your approach to doing cataract surgery in this eye. Please address the following challenges and how you would approach them:

  • white cataract (is it likely dense or soft? intumescent or hard?)
  • capsulorhexis creation, small pupil
  • low corneal endothelial cell count
  • and anything else you wish.

Please leave your written answer in the comments section below!

Thank you!

All content is ©2018 Uday Devgan MD. All rights reserved.


  1. White cataract in the question 8 seems intumescent and not v hard. My approach would be to put a pupil expander for a better visualisation then stain the capsule with tryapn blue under visco. After giving a Konica on capsule would irrigate fluid to avoid Argentinian flag and then continue rhexis with a forceps with centripetal force to avoid outgoing of rhexis.As endothelial count is less would use a good dispersive viscoelastic material like viscoat to protect endothelium and then use a cohesive (soft shell technique).

  2. regarding management options in question 8, endothelial cell density is too low for a good post operative outcome; so first step should be to do phacoemulsification using iris hooks and soft shell technique followed by Endothelial keratoplasty (DSEK)!!

    1. Good thoughts. This could be done in two steps. The cataract surgery first. Then if the post op vision is good, stop there. If not and the cornea declines, then DSEK could be done. Perhaps aiming for a -1 post op refractive outcome for the IOL calcs would be a good move.

  3. preop counselling of Guarded visual prognosis. Pt should be counselled about may need DMEK /DSAEK sx in future.
    preop IV mannitol.
    Intraop continuous well maintain ant chamber pressure.
    Intracameral xylo+phenyl ephrine.
    Insertion of pupil expander ring.(No iris hook)
    Snail like capsulorhexis. Aspiration of cortical fluid from front as well as behind the nucleus .
    phaco sx perform with low phaco power (soft shell technique)

    Also be prepare for pars plana vitrectomy.Keep CTR ring ready.

    1. Great ideas and approach. I like your idea of a snail-like capsulorhexis to carefully spiral it out to the desired size. Thank you for contributing.

  4. Future management of this case will be:

    A new drop who can dilate any small pupil.
    Ant seg OCT guided insertion of Femtosecond laser microdevice in Endonuclues.Energy level depend upon nucleus density.
    It will fragment endonucleus in 4 quadrant. Rest procedure will be done by Phaco .
    If endothelial loss occur then cultivated endothelial transplantation.

    1. Sounds like a great future. Certainly cataract surgery will continue to evolve and I’m excited to see the progress that we make. Thank you for your comments.

  5. Limbal incision, staining of capsule with trypan blue. Soft shell technique using viscoat. Slow – mo phaco ( all parameters low ). In the bag implantation of Hydrophobic IOL. Postoperative assessment for corneal endothelial status for deciding about Further procedure ( sometimes they do fantastic even with very low counts. )

  6. I will take up the case under subtenon’s or peribulbar anaesthesia with I.V Mannitol preoperatively. I will prefer to do a scleral tunnel avoiding graft host junction. As it was a therapeutic P.K. large graft was taken. I will make sideport incision in the recepient cornea to prevent further damage to low endothelial cell count.Pupil expander for small pupil management. Liberal use of Viscoat. Emulsification at a much posterior plane to prevent further damage to the corneal endothelium. Counselliing the patient for DSEK in future. Not to remove remaining sutures. Only loose sutures to be removed.

  7. Sir challenges in this kind of cases are many and prognosis should be guarded and explained.Cataract in the picture doesn’t look very hard (About Grade 3 plus)but as the patient is diabetic we need to keep in mind the leathery nature of fibres associated with diabetic cataracts and associated zonular weakness.Also there are chances of rhexis run out.I would proceed the case with a clear cornea Phaco using a pupil expanding device preferably a malyugin ring (Iris hooks won’t be a good idea considering the sutures present in the cornea and might lead to shallowing of AC).I would prefer doing a double rhexis technique from the side port using microforceps and scissors.Very cautious hydrodissection if needed avoiding the prolapse of Nucleus in AC and under the cover of a good dispersive visco like viscoat and a soft shell technique I would try to take out the nucleus using direct chop.Keeping things slow and controlled and frequent filling of AC and coating the endothelium with viscoat we can give an appreciably good visual outcome

  8. Peri bulbar block, Scleral Tunnel, phaco, malyugin ring, Iris hooks are out due to large graft. Viscoat plenty. Side port close to limbus

  9. In Small pupils rhexsis is challenging First step is detailed informed consent. Viscodilation using provisc & start rhexsis using cystitome anti-clockwise under the iris edge & thus complete the procedure

  10. Excellent thoughts. I like your first step of a detailed informed consent. I did not specifically mention that in the article, but I will keep that in mind for future articles. Great point!

  11. For case number 8, I think the best would be if a cornea-cataract surgeon would do the case.
    If not possible, then my approach would be a more scleral main incision, soft shell technique, VB under viscoelastic to protect the endothelium, probably better iris hooks than ring- less manipulation in the AC, better for endothelium, snail-like rexis, phaco-chop technique to remove the cataract, IOL in the bag.
    Of course, before surgery, the patient needs to be made aware about the risks of the procedure.
    I have seen cases like this done by cornea-cataract surgeon and it went wonderfully well.
    I am a junior cataract surgeon, I’ve done 200 cases so far, so likely that this case would not be for me. I would definitely send to a senior colleague.

    1. Thank you for your excellent reply and suggestions. There is no need for a “cornea-cataract surgeon” because a good and talented cataract surgeon can handle this case quite easily. The patient does not require any further corneal surgery and a well-done cataract surgery in this case will be sufficient to complete this case and restore vision.

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