14   Cortically Mature Lens: White Cataract

There are two basic types of white cataracts that are distinguishable at the slit lamp: pearly white and homogeneously white. The pearly white variety is characterized by having some degree of variegation in its white appearance and can vary on a spectrum from being mostly white with a tinge of an amber hue (Fig. 14.1a), to stark white with significant variegation (Fig. 14.2a), to being all white with only trace variegation (Fig. 14.3). A pearly white cataract variety may be nonliquefied (Fig. 14.1b), or may be somewhat liquefied (Fig. 14.2b). It is this latter variety that has increased intralenticular pressure, hence its description as being intumescent. The intumescent white cataract is always at risk for a tear out of the continuous curvilinear capsulotomy during its creation, resulting in an Argentinean flag sign (Fig. 14.4a); the seminal article postulating the cause of this was published in 2012 by Fiqueiredo et al.¹

Figueiredo et al explain that within the capsular bag of an intumescent cataract is liquefied cortex that is located both anteriorly and posteriorly to the nucleus. They postulate that these two liquid compartments do not connect with each other due to the large nucleus making contact with the equatorial capsule, causing relative nuclear block (Fig. 14.2b). Consequently, after puncturing the anterior capsule when initiating a capsulotomy, the anterior intralenticular compartment decompresses but not the posterior compartment (Fig. 14.4b). As the performance of the capsulotomy proceeds, the posterior intralenticular compartment, which is still pressurized, causes the nucleus to move anteriorly, and this force, in turn, causes the incomplete capsulorrhexis to radialize toward the periphery so quickly that retrieval is not possible.

The homogeneously white cataract is confluently pale white in color without any variegation (Fig. 14.5a). It appears this way due to significant liquefaction of the lens, causing the nucleus to be free floating (Fig. 14.6a). This type of cataract is also termed a Morgagnian. Some authors call this type of cataract “intumescent,” and it is under pressure, but there is low risk of an Argentinean flag sign occurring as long as the anterior chamber is well pressurized with an ophthalmic viscosurgical device (OVD), preferably a dispersive OVD or heavy cohesive such as Healon 5® (Abbott Medical Optics [AMO], Abbott Park, IL), when the tense anterior capsule is punctured with a 30-gauge needle at the time of capsulotomy creation. Figueiredo shows diagrammatically (Fig. 14.5b) that in a Morgagnian cataract, the anterior and posterior intralenticular compartments freely communicate. Hence, capsular puncture, at the initiation of the capsulotomy, effectively decompresses both the anterior and posterior spaces, thus averting the capsulotomy from tearing out during its creation. The capsular bag may decompress so significantly that it may be necessary to firm up the bag with an OVD prior to proceeding with a continuous curvilinear capsulotomy creation.

Brazitikos et al² classified white cataracts using A-scan echography. In their series of 100 consecutive white cataracts, the cataracts with liquid cortex had high internal acoustic reflections compared with the ones with a solid cortex that showed low internal acoustic reflectivity (Fig. 14.7). Thus, close examination of preoperative A-scans of white cataracts may alert the surgeon to the presence of liquid cortex and the need for following Figueiredo’s intumescent cataract surgical protocol to prevent an Argentinean flag sign complication.

Schultz and Dick³ and Steinert and Dick⁴ have commented on the ability of the spectral-domain optical coherence tomography system in the Catalys Femtosecond Laser System (Abbott Medical Optics) to identify intralenticular fluid spaces within intumescent white cataracts (Fig. 14.8). They follow a specific femtosecond laser protocol for intumescent cataracts that is discussed later in this chapter.

Surgical Technique

The ideal surgical approach to a mature cortical cataract can be delineated as follows: (1) minimize posterior pressure, (2) use Trypan blue dye, (3) create a 3-mm capsulotomy and enlarge it to 5 mm after decompression of the anterior and posterior cortical spaces, and (4) perform phacoemulsification and intraocular lens (IOL) placement.

Minimize Posterior Pressure

Even though intralenticular pressure in the intumescent cataract is the main cause of radialization of a capsulotomy tear, minimization of any other source of posterior pressure is advisable to further optimize conditions for a successful case outcome. Figueiredo et al¹ recommend 250 cc of 20% intravenous (IV) mannitol 50 minutes prior to surgery. Also, if the surgeon is using a retro- or peribulbar anesthetic block, I recommend the use of a Honan balloon or Mercury bag to soften the orbit and reduce the posterior pressure. It is important to always ensure that the lid speculum is loosely opened so that it does not cause pressure on the eyelids that, in turn, can cause posterior pressure. Gorovoy and Jeng⁵ recommend a prophylactic peripheral iridotomy prior to intumescent white cataract surgery, theorizing that this will minimize pressure in the posterior chamber that can in a minor way help to reduce the chance of an Argentinean flag sign from occurring.

Fig. 14.1 White cataract with no liquid cortex. (a) Photograph. (b) Illustration. (From EyeRounds.org. Reprinted by permission.)

Fig. 14.2 (a) Intumescent pearly white cataract with significant variegation. (a, Reused with permssion from Figueiredo CG, Figueiredo J, Figueiredo, GB. Brazilian technique for prevention of the Argentinean flag sign in white cataract J Cataract Refract Surg 2012; 38:1531–1536.) (b) Illustration of a liquefied cortex under pressure, both anterior and posterior to the nucleus. Figueiredo postulates that these two liquefied, pressurized compartments do not communicate due to nuclear block. A is the anterior intralenticular pressurized cortical compartment; B is the posterior intralenticular pressurized cortical compartment. (b, Adapted from Figueiredo CG, Figueiredo J, Figueiredo, GB. Brazilian technique for prevention of the Argentinean flag sign in white cataract J Cataract Refract Surg 2012;38: 1531–1536.)

Fig. 14.3 Intumescent pearly white cataract with trace variegation.

The use of indocyanine green capsular (ICG) dye to facilitate capsulorrhexis creation was initially reported by Horiguchi et al⁶ in 1998 and was a monumental advancement in the treatment of white cataracts. Melles et al⁷ reported on the usage of trypan blue dye (Vision Blue®, DORC, Zuidland, The Netherlands) in 1999. Even though both ICG dye and trypan blue dye adequately stain the anterior capsule of a white cataract, Chang⁸ compared the two dyes and found that trypan blue provides a significantly darker, more intense and persistent staining of the anterior capsule. This may be especially beneficial in improving visualization during phacoemulsification in a patient with preexisting corneal edema, prominent arcus senilis, or corneal scarring. Being able to see the edge of the continuous curvilinear capsulotomy helps the surgeon avoid damaging the capsule during phacoemulsification in difficult cases where there is no red reflex.

Fig. 14.4 (a) Argentinean flag sign occurring at the initiation of the capsulorrhexis. (b) Illustration of the proposed mechanism by which the Argentinean flag sign occurs. After decompression of the anterior cortical space, the pressurized posterior liquefied cortex pushes the nucleus anteriorly, causing the initial capsular tear to extend toward the equator. (b, Adapted from Figueiredo CG, Figueiredo J, Figueiredo, GB. Brazilian technique for prevention of the Argentinean flag sign in white cataract J Cataract Refract Surg 2012;38:1531–1536.)

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