Review: Differentiating White Cataracts

You’ve seen the notation in the patient chart: “DWC” which stands for Dense White Cataract, but there is actually a spectrum of cataracts that appear to be white. And they are not all dense and they can behave very differently during surgery. There is a way to differentiate white cataracts during the pre-operative consultation so that you can determine how best to approach the surgery, which techniques to use, and what potential complications are possible. (scroll down for the full video)

The nuclear density can vary greatly, with some white cataracts being soft, milky, and intumescent in nature, while others can be hard and rock-like with a high degree of nuclear sclerosis. The differentiation between a dense white cataract and a soft white cataract is important in devising a surgical plan for phacoemulsification.

Dense white cataracts tend to be in older patients and on slit lamp examination there is a yellow to brown hue to the central portion of the crystalline lens. The anterior capsule tends to look relatively flat with no evidence of fluid within the capsular bag. Once the capsule is stained with trypan blue dye, the capsulorrhexis should be fairly routine with little risk of radialization. However, due to the density of the nucleus a larger degree of ultrasonic phaco energy will likely be required and the risk of corneal endothelial trauma or even phaco wound burn is higher. For these eyes, re-coating the endothelium with a dispersive viscoelastic during phaco and utilizing ultrasonic power modulations can help to lessen the risks.

Soft white cataracts tend to be in younger patients where there is a milky, white fluid within the capsular bag. These white intumescent cataracts pose a challenge during capsulorrhexis creation because the intra-lenticular pressure increases as the lens cortex liquefies. In a routine cataract, the lens material is solid and the pressure within the capsular bag is lower than the pressure in the anterior chamber, making capsulorrhexis creation straightforward. But with the white intumescent cataract, the liquefied cortex increases the intracapsular pressure and forces the capsular bag to rip uncontrollably once it is opened.

The three main questions that we need to ask are:

  1. Is there fluid from decomposed lens proteins within the capsular bag?
  2. Is the nucleus dense or relatively soft?
  3. Are there any associated abnormalities?

When looking at a patient with a white, totally opaque cataract at the slit-lamp microscope, we are looking for clues which will help us answer these questions.

The first clue is the color of the cataract: is it more of a blue hue or a yellow hue?

color gradient of white cataracts

Below are examples of white cataracts with a blue hue:

white cataracts - bluish

Above, A: slit-lamp view showing bluish hue, B: even without a microscope there is a blue tint to the white cataracts, C: another bluish white cataract, D: trypan blue dye used to stain the capsule, but look within the capsular opening and note the blue hue (not from dye).

The bluish hue in a white cataract is due to liquified lens cortex, which makes this an intumescent white cataract. This cataract will typically be relatively soft and less dense, but that does not make the surgery easier. Rather, the pressure within the capsular bag can cause the capsulorhexis to radialize and rip out to the zonules (and sometimes into the posterior capsule) in what is called the Argentinian Flag Sign due to its resemblance to that country’s flag:

Argentinian flag sign

The dreaded Argentinian flag sign is due to pressure within the capsular bag due to the liquified cortex (intumescent cataract). This can be avoided with special techniques which will be explained in detail in the upcoming new articles and videos here on in the next few days. White cataracts with a slight yellow or brown hue tend to be more dense with less fluid within the capsular bag (and less of a risk of Argentinian Flag Sign).

Below are examples of white cataracts with yellow hues

white cataracts - yellowish

Above, A: white cataract with slight yellow / brown tint showing dense nuclear sclerosis, B: very mature white cataract with yellowish hue, C: mostly yellow tinted but slight blue indicating some liquefaction of lens cortex, D: central nuclear sclerosis with yellow tint, with periphery of cataract showing less opacity indicating intact (non-liquid) cortex.

Finally, when examining these patients during the pre-op consultation, look carefully for any other abnormalities. While these are not common, their presence can mean an entirely different surgical approach is needed.

Below are examples of white cataracts with other issues

white cataracts - unusual

Above, A: This white cataract also has severe contraction of the anterior capsule with retraction causing a gap between the iris and lens, B: This patient has dislocation of the entire cataractous lens into the anterior chamber due to severe zonular laxity, C: The lens equator is visible in one sector due to congenital absence of zonular structures, D: This patient has a white cataract but also has aniridia.

Today, our take home message is to ask yourself these questions:

  1. Is the cataract bluish or yellowish?  
  2. Is the cataract hard/dense or soft/liquefied? 
  3. Are there any other abnormalities?

In my experience over the past 20 years, the distribution is approximately:

white cataract distribution

click below to see a video of dense white cataract surgery:


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