Intumescent white cataracts pose a challenge because the lens cortex has degenerated so much that is has liquefied. This creates a pressure within the capsular bag and it can cause the nucleus to push forwards during capsulorhexis creation, resulting in capsule run-out and a complication known as the Argentinian Flag Sign.
One technique to avoid this is the double capsulorhexis technique which creates an initial small capsular opening through which we can decompress the capsular bag. We make the first, small capsulorhexis via a paracentesis incision with the anterior chamber pressurized so that the pressure is higher than in the capsular bag. Once that first capsular opening is created, the lens nucleus can be rocked and shifted to release the pressure from the capsular bag and allow egress of fluid. Recently, I showed a case like this with a large degree of milky fluid egress.
Other techniques include using a needle or the phaco probe to puncture the anterior lens capsule to decompress and aspirate the fluid. We can also use a femtosecond laser to instantly create the capsulotomy before making the first incision. Just be careful since this method can sometimes leave adherent tags at the capsule margin.
An additional bonus in this case: to assist the resident in removing the cataract, I use the chopper with a simple cannula to break the cataract into halves and then into quarters. This makes it very easy for the resident surgeon to emulsify and aspirate the nuclear pieces. This is a must-see technique.
Click below to learn from this video which was performed by a resident in training: