3
GUEST EDITORIAL
Pearls for the young cataract surgeon:
the white cataract
Robert H. Osher, MD
This column is one in an invited series by Dr. Osher.
The series highlights techniques that may be helpful in
particular to young practitioners.
There are multiple types of cataracts that fall under the
category of “white,” and it is important to differentiate because
each behaves differently. Moreover, the surgical approach is
very different. Let us begin this column by classifying white
cataracts as nuclear/cortical, intumescent, or Morgagnian.
NUCLEAR/CORTICAL
This is the easiest white cataract to deal with because it
represents nuclear sclerosis and/or cortical opacification.
Visualization is key, and the anterior capsule should be
stained with trypan blue. A confluent white cortex may be
adherent to the capsule, so an effective hydrodissection is
important. It may be necessary to liberate recalcitrant
corticocapsular adhesions by viscodissection with a co-
hesive ophthalmic viscosurgical device (OVD). The sur-
geon should expect this case to go smoothly.
INTUMESCENT
This is the white cataract with the most potential for a
surgical complication. It is usually present in a younger
patient, and the anterior cortex has a “frothy” appearance.
The slit beam will show a “flare” as it passes through the
anterior cortex, and the examiner can expect diagnostic
testing to reveal a lens thickness over 5 mm. This is the
cataract which is associated with the feared Argentinian flag
sign first reported by Perrone and Albertazzi from
Argentina.1
The best article which discusses this cataract was written
by Figueiredo in 2012 in which a brilliant explanation for
the Argentinian flag was proposed.2 Dr. Figueiredo hy-
pothesized that a relative nuclear block creates a separate
anterior and posterior cortical compartment. As the cortex
becomes hydrated, the entire lens develops an increased
intralenticular pressure. However, each compartment also
has a separate increased pressure which would explain why
simple decompression of the anterior cortex could still
result in an Argentinian flag sign as the nucleus is pushed
forward causing the opening in the anterior capsule to
extend peripherally toward the equator. The key maneuver
From the Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Eye Institute, Cincinnati, Ohio.
Corresponding author: Robert H. Osher, MD, Cincinnati Eye Institute, 1945 CEI Dr, Cincinnati, OH 45242. Email: rhosher@cvphealth.com.
Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS
Published by Wolters Kluwer Health, Inc.
Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.
after decompressing the anterior compartment is to push
the nucleus back toward the posterior capsule breaking the
relative block and decompressing the posterior cortical
compartment (Video 1, http://links.lww.com/JRS/A691).
Once this is accomplished, the remainder of the surgery
becomes uneventful.
Let us summarize the key steps in managing the in-
tumescent cataract: (1) Stain the anterior capsule with trypan
blue. (2) Inject a retentive OVD flattening the lens capsule and
overcoming the gradient produced by increased intralenticular
pressure. (3) Puncture the anterior capsule which releases the
pressure in the anterior cortical compartment, then continuing
to ballot the nucleus posteriorly, which effectively decom-
presses the posterior cortical compartment. Dr. Figueiredo
called this “posterior voiding.” (4) A smaller capsulorhexis will
not tend to run along the anterior lens bow toward the pe-
riphery, and it can be safely enlarged if necessary at a later time.
By following these recommendations, the Argentinian
flag can be confined to Latin America!
MORGAGNIAN
This cataract develops because of chronic liquefaction of the
cortex. The milky cortex completely surrounds a hard, ball
bearing-like nucleus, which usually sinks with gravity into
the inferior capsular bag. The challenge of a completely
liquefied cortex is the collapse of the capsular bag after the
milky cortical fluid has escaped into the anterior chamber
once the anterior capsule is punctured. The surgeon should
refill the capsular bag by injecting an OVD, widely separating
the anterior from the posterior capsule (Video 2, http://
links.lww.com/JRS/A692). Otherwise, it is possible to tear the
posterior capsule while performing the anterior capsulo-
rhexis. Again, visualization is critical, so the procedure begins
by staining the anterior capsule with trypan blue. This dye
has been reported to make the anterior capsule more brittle
as reported separately by Dr. Ehud Assia from Israel and
published by Dr. Burkhard Dick from Germany.3 Dr. Minu
Mathen from India has suggested that this tendency toward a
brittle capsule can be minimized by washing out the diluted
dye quickly.4 Next, Healon 5 (my preference) is injected into
the anterior chamber and into the capsular bag. The cap-
sulorhexis is more difficult to perform when there is no
underlying cortical support, so a forceps rather than a needle
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4 GUEST EDITORIAL
may be necessary. After the capsulorhexis has been com-
pleted, the surgeon can look forward to a longer emulsifi-
cation, given the hardness of the nucleus. Extra caution is
necessary because there is no posterior cortical plate to
protect the posterior capsule. The posterior capsule may have
a fibrotic plaque, given the longstanding presence of this
cataract. If an edge can be elevated, the plaque can be dis-
sected off the posterior capsule with an intraocular forceps or
the surgeon may leave the capsule alone for a subsequent
YAG laser posterior capsulotomy.
All 3 white cataracts share in common the necessity of
using a capsular dye and the size of the rhexis should be
created with the possibility in mind that optic capture may
be required. Successful surgery is always satisfying for the
surgeon and may represent a life-changing gift to the
patient who has suffered with a white cataract.
Volume 49 Issue 1 January 2023
Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.
REFERENCES
1. Perrone D, Albertazzi R. Argentina flag sign. Video J Cataract Refract Surg
2001;XVII
2. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for pre-
vention of the Argentinean flag sign in white cataract. J Cataract Refract Surg
2012;38:1532–1536
3. Dick HB, Aliyeva SE, Hengerer F. Effect of trypan blue on the elasticity of the
human anterior lens capsule. J Cataract Refract Surg 2008;34:1367–1373
4. Mathen M. Morgagnian. Video J Cataract Refract Glaucoma Surg 2020;36
Disclosures: The author has no financial or proprietary interest in
any material or method mentioned.
First author:
Robert H. Osher, MD
Department of Ophthalmology, University of Cincinnati College
of Medicine, Cincinnati, Ohio