An alternative endocapsular approach for the management of Argentinean flag capsular tear during cataract surgery

Abstract

Many techniques are employed to prevent the formation of a radial anterior capsular tear which resembles an Argentinean flag during surgery for the extraction of white mature cataract. We aim to describe an original endocapsular approach to manage this intraoperative complication once it has already occurred, which was employed in four eyes of four patients, all with mature white cataracts prior surgery. Using this technique, without hydrodissection, the surgeon proceeds with phacoemulsification through the slit of the open anterior capsule. The anterior capsule is only manipulated following intraocular lens (IOL) insertion to the capsular bag by creating two symmetric semicircles. In all cases, no posterior capsular tear occurred during surgery, and there were no further intraor post-operative complications. The final best-corrected visual acuity was 20/25 in each case on the 3-month follow-up appointment, and the IOLs were well centered in the capsular bag. capsulorhexis,[1] creating peripheral iridotomies,[8] and capsule milking, as lately described by Chee and Chan.[9] Some surgeons routinely inject intravenous mannitol preoperatively in those cases and/or use viscoelastic agents such as Healon5® intraoperatively (Johnson & Johnson Vision, Santa Ana, CA, USA).[10] Emerging technologies for automated capsulotomy such as the nanopulse capsulotomy (Zepto, Mynosys Cellular Devices, Inc.), and CAPSULaser (Excel-Lens, Inc.) may have a value in preventing this complication, though efficacy is yet to be proven. Nevertheless, and despite the best of efforts, an Argentinean flag sign may still be observed in these complex cases. Once this complication has occurred, it is imperative for the surgeon to meticulously plan the next steps. The main concern is to avoid tear propagation to the posterior capsule, which may lead to capsular or zonular tears, vitreous loss and dropped nucleus, or intraocular lens (IOL).[11] There are, however, no guidelines or explicit recommendations for the management of such complications. We, therefore, report our technique to perform phacoemulsification without hydrodissection through the slit inadvertently created in the anterior capsule. The anterior capsule is only manipulated following IOL insertion to the