Transcript Alex Tham, Colin S.H. Tan, Christopher Khng

The Invisible Argentinean Flag – Massive
Anterior Capsule Split during Viscoelastic
Injection

Objectives:
 To describe an unusual case of sudden, massive
anterior capsule split extending to the equator in a
soft cataract
 To suggest a mechanism to explain this
phenomenon.

An 80-year-old man with
nuclear sclerotic 2+ cataract
and 20/60 vision was listed for
phacoemulsification

The nucleus was noted to be
relatively small with a larger
cortical component.

During the side-port incision, the
anterior capsule was
inadvertently engaged (Fig 1)

This caused a 0.3mm linear
puncture in the anterior capsule
Figure 1. The tip of the Beaver blade
engages the anterior capsule (white
arrow) during the side-port incision.

After viscoelastic injection, a
large equator-to-equator
anterior capsule split was
observed (Fig 2)

There was no vitreous loss.

The surgery was converted
to a corneal-section
extracapsular cataract
extraction, which proceeded
uneventfully.
Figure 2. Following viscoelastic
injection, there is a massive anterior
capsule split (demarcated by white
arrows) extending to the equator.

After viscoelastic injection, a
large equator-to-equator
anterior capsule split was
observed (Fig 2)

There was no vitreous loss.

The surgery was converted
to a corneal-section
extracapsular cataract
extraction, which proceeded
uneventfully.
Figure 2. Following viscoelastic
injection, there is a massive anterior
capsule split (demarcated by white
arrows) extending to the equator.

The safety of phacoemuslfication is
dependent on an intact capsulorrhexis
[1].

In some cases of white mature cataracts
 There is a high endolenticular pressure
 This may cause a tear in the anterior
capsule to extend to the periphery.

If trypan blue is used to stain the anterior
capsule[2]
 the result is a central band of white
surrounded on either side by bands of
blue – the Argentinean flag sign [3].

A similar anterior capsule split occurred in our patient.
 The anterior capsule was not stained as the cataract
was relatively soft;
 Hence the lack of the alternating colored bands, and
thus the “invisible Argentinean flag”.

The cataract morphology was not the type commonly
associated with a high endolenticular pressure.

The tiny puncture in the anterior capsule did not extend
initially.

It extended after the viscoelastic was injected into the
anterior chamber, which was slightly overfilled.
Proposed Mechanism

Anesthetic fluid volume from the peribulbar injection
contributed to raised orbital [4,5] and vitreous [6] pressure.

The viscoelastic injection resulted in raised anterior chamber
pressure, with consequent compression of the lens between
these opposing two forces.
Diagram taken from http://www.osnsupersite.com/view.aspx?rid=14207
Done by Dr Daniel Mario Perrone, MD
Proposed Mechanism

Under such pressure, soft lens matter extruded through the anterior
capsular puncture, resulting in a split propagating to the periphery in
both directions.

The type of cataract, with a greater soft cortical component, also likely
played a major factor in the occurrence of this complication.

A dense brunescent lens with little cortical component would be more
resistant to such compression forces.
Diagram taken from http://www.osnsupersite.com/view.aspx?rid=14207
Done by Dr Daniel Mario Perrone, MD

This was found true in a subsequent surgery on a dense,
brunescent cataract in a 63-year-old man.
 Inadvertent puncture of the anterior capsule resulted in a 0.5 mm defect
 This remained stable even when the anterior chamber was filled
completely with viscoelastic.
Conclusion:

This case illustrates the potential for a large anterior capsule
split in softer lenses during viscoelastic injection.

Surgeons should exercise great caution when proceeding with
phacoemulsification

They may wish to convert to extracapsular cataract extraction.
1.
Gimbel HV, Neuhann T. Development, advantages, and methods of the
continuous circular capsulorhexis technique. J Cataract Refract Surg 1990;
16(1):31-37.
2.
Melles GR, de Waard PW, Pameyer JH, Hoadijn Beekhuis W. Trypan blue
capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract
Refract Surg 1999; 25:7-9.
3.
Perrone D, Albertazzi R. The Argentinean flag sign. Video Journal of Cataract
and Refractive Surgery. 2001; Vol. 17:Issue 1.
4.
Riemann CD, Foster JA, Kosmorsky GS. Direct orbital manometry in patients
with thyroid-associated orbitopathy. Ophthalmology 1999; 106(7):1296-1302.
5.
Riemann CD, Foster JA, Kosmorsky GS. Direct orbital manometry in healthy
patients. Ophthal Plast Reconstr Surg 1999; 15(2):121-125.
6.
Watkins R, Beigi B, Yates M, Chang B, Linardos E. Intraocular pressure and
pulsatile ocular blood flow after retrobulbar and peribulbar anaesthesia. Br J
Ophthalmol 2001; 85(7):796-798.