Dr. Mohan Rajan, M02916, Dr. Sujatha Mohan
The most challenging step in handling an intumescent cataract is the creation of a well-sized round and centered Continuous Curvilinear Capsulorhexis(CCC). In these mature cataracts, the capsule tends to bethin and fragile and the absent red reflex results in poor visualization of the capsule edge during capsulorhexis(1,2).Due to the high intralenticularpressure(3,4) the capsulorhexis tear has a tendency to extend to the periphery, forming a radial tear that produces the Argentinian flag sign.This may progress to complications including zonular or posterior capsule tears, vitreous loss, and intraocular lens (IOL) decentration.Recently, new methods such as the femtosecond laser capsulotomy, the nanopulsecapsulotomy (Zepto, Mynosys Cellular Devices, Inc.), and Capsulasor (Excel-Lens, Inc.) in which the laser is selectively absorbed by the trypan blue staining the capsule,have been introduced. Although these technologies automate the capsulotomy and reduce the dependence on surgical skill, they add to the cost of the cataract procedure. Furthermore, whether these technologies safely create a complete capsulotomy in intumescent cataracts has not been studied.
In this study,punchorhexis a novel method is attempted where simultaneous puncture of the anterior capsule and decompression of the capsular bag done there by causing decrease in intralenticular pressure. It is therefore crucial in preventing an uncontrolled radial extension of tear(Argentinian flag sign)(5,6).
Purpose: To prevent Argentinian flag sign during capsulorrhexis in white mature and intumuscent cataracts.
It is a prospective interventional study done over a period of 6 months.242 eyes with white intumescent cataract were included in this study. All patients underwent detailed ophthalmological examination which included Slitlamp examination, A scan, B scan, preoperative IOL power calculation(IOL Master Carl Zeiss) and Intraocular pressure measured by non contact tonometry.
Exclusion criteria were history of coexisting ocular diseases like uncontrolled glaucoma, ocular tumors, ocular trauma, pseudoexfoliation syndrome, zonular dialysis, poorly dilating pupil(pupil<6mm).
The same experienced surgeon performed all phacoemulsification procedures using the same technique.Under Peribulbar anesthesia, the volume of anesthetic injected should be adequate to induce akinesiaand analgesia but not a firm globe. Globe compressionshould be performed if the eye is firm after the injection. The side-port incision is made, and then the main temporal clear corneal incision is created using a keratome.The capsule is stained with 0.06% trypan blue andthe anterior chamber completely filled with OVD.Using the main corneal incision , phacoemulsification probe inserted into anterior chamber andPunchcapsulorhexis was done with a bevel down 15 degree phaco needle using high vacuum and burst phaco(Vacuum : 350 – 400mm Hg, Phaco Power : 40%).Due to sudden burst of phaco power there is sudden decompression of lens bag and decrease in intralenticular pressure. Once the punch was made the capsulorrhexis was completed with uttrataforceps.Phacoemulsificationwas further performed without hydrodissection using a stellarisphacoemulsification system followed by foldable hydrophilic single piece acrylic IOL implantation.
The study comprised 242 eyes of 242 patients. The mean age was 65.3 years.Thepunchorhexis prevented Argentinian flag sign in 239(98.7%) eyes out of 242 eyes. Postoperatively there were no complications
An intumescent lens puts the surgeon at risk for Argentinian Flag Sign during capsulorhexis, running away of rhexis, posterior capsular tear, zonular rupture.Simultaneous puncture of the anterior capsule and decompression of the bag is therefore crucial in preventing an uncontrolled radial extension of tear(7,8).This technique not only ensures the initial decompression, but also prevents a catastrophic Argentinian flag sign. It also facilitates the controlled creationof a capsulorhexis of a desired size. However, in eyes with phacomorphic glaucoma in which the anterior chamber is extremelyshallow, this technique may be challenging, especiallywhen the cornea becomes hazy with an increase in intraocularpressure during the CCC procedure.
In conclusion, Punchorhexistechnique for intumescent cataracts is a successfuland reproducible method of achieving a well-sized CCC.
1. Ermis¸ SS, Ozturk F, Inan U.U. Comparing the efficacy and safety of phacoemulsification in white mature and other types of senile cataracts. Br J Ophthalmol2003; 87:1356–1359.
2. Bhattacharjee K, Bhattacharjee H, GoswamiBJ,Sarma P. Capsulorhexis in intumescent cataract. J Cataract Refract Surg 1999; 25:1045–1047.
3. Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg 1990; 16:31–37
4. Assia EI, Apple DJ, Barden A, Tsai JC, Castaneda VE, Hoggatt JS. Anexperimental study comparing various anterior capsulectomy techniques. Arch Ophthalmol 1991; 109:642–647
5. Rao SK, Padmanabhan P. Capsulorhexis in eyes with phacomorphic glaucoma. J Cataract Refract Surg 1998; 24:882–884
6. Gimbel HV. Two-stage capsulorhexis for endocapsular phacoemulsification. J Cataract Refract Surg 1990; 16:246–249
7. Rao SK, Padmanabhan P. Capsulorhexis in eyes with phacomorphic glaucoma. J Cataract Refract Surg 1998; 24:882–884
8. Gimbel HV. Two-stage capsulorhexis for endocapsular phacoemulsification. J Cataract Refract Surg 1990; 16:246–249