We have studied intumescent white cataracts many times here on CataractCoach and we know that the primary challenge is that the capsular bag is under pressure. The liquefied lens cortex creates a fluidic pressure within the capsular bag and when a traditional capsulorhexis is attempted, this can cause a sudden radialization often dubbed the Argentinian Flag Sign.
The idea behind using a femtosecond laser is that we can create the capsulorhexis while the anterior chamber is pressurized and prior to entering the eye with surgical instruments. Sometimes this works very well and other times it can leave persistent attachments. And given the suction ring that couples the eye to the laser, we can often also see subconjunctival hemorrhage like this.
In the case presented here, once the femtosecond laser started creating the capsulorhexis, liquefied lens cortex started to leak out of the capsular bag and into the anterior chamber. This makes the aqueous more opaque, thereby blocking the transmission of the laser energy. And the result is what we have here: an incomplete capsulotomy.
Fortunately, we can stabilize the capsular flap with viscoelastic (and you’ll see that I created an extra paracentesis incision so that the viscoelastic could be injected in the desired direction). Then our capsulorhexis forceps were used to safely complete the anterior capsular opening.
Click below to learn how to recover from an incomplete femtosecond laser capsulotomy:
Great case, it looks like you only pulled centrally and the entire area from 4-7 o’clock came off nicely and left you with a nice round capsulorhexis. Could you have turned the flap over at 7oclock and act as if you were doing a CCC and pulled in a circular motion towards 4oclock? Or was it that b/w 4-7 o’clock the femtosecond laser partially created the CCC and there were only small adhesions left to break and pulling centrally broke them all simultaneously? Thank you!
yes, that would work also.