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598

ARTICLE

Real-time intraoperative dynamics of

white cataract—intraoperative optical
coherence tomography–guided classification and
management
Jeewan S. Titiyal, MD, Manpreet Kaur, MD, Farin Shaikh, MD, Siddhi Goel, MD, Lalit MS Bageshwar, BSc

Purpose: To evaluate morphological characteristics and intra- homogenous ground-glass appearance of the anterior lens cortex.
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operative dynamics of different types of white cataract using intra-
operative optical coherence tomography (iOCT).
Setting: Dr. Rajendra Prasad Center for Ophthalmic Sciences, All
India Institute of Medical Sciences, New Delhi, India.
Design: Prospective interventional study.
Methods: Fifty eyes with white cataract undergoing phacoemul-
sification were evaluated. The primary outcome measure was the
classification of white cataract based on morphology and intra-
operative dynamics on iOCT. The secondary outcome measure was
rhexis-related complications.
Results: Four types of white cataract were identified based on iOCT
—type I (9 eyes), type II (3 eyes), type III (24 eyes), and type IV (14
eyes). Type I had regularly arranged lamellar cortical fibers, type II
had continuous hyperreflective bands of cortical fibers with intra-
Capsulorhexis in type I cataract was uneventful. In type II cataract,
cortical bulge was observed in the anterior chamber on creating
the initial nick, indicating raised intralenticular pressure (ILP) with
an imminent risk of rhexis extension. A bimanual irrigation/aspiration
was performed until lowering of ILP was observed on iOCT. In
types III and IV, fluid release was observed on initiation of rhexis
leading to partial (type III) or complete (type IV) lowering of ILP,
with a mild-moderate risk of capsulorhexis extension. A continuous
curvilinear capsulorhexis was achieved in all cases, with no case
of posterior capsular tear or vitreous loss.
Conclusions: Intraoperative OCT helped elucidate intraoperative
dynamics of the spectrum of white cataracts and facilitates completion
of capsulorhexis.
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lenticular clefts, type III had intralenticular clefts combined with areas
Online Video
of homogenous ground-glass appearance, and type IV had

increasingly being used as an aid to facilitate decision

challenging owing to an absence of red reflex on making in various anterior and posterior segment
The management of white
retroillumination, cataracts is surgically
capsulorhexis-related problems surgeries.9–13 Microscope-integrated iOCT provides an
owing to raised intralenticular pressure (ILP), and lack of ultrastructural view of the anterior segment during pha-
adequate cortical support during phacoemulsification.1,2 coemulsification and may be used to assess the lenticular
Different techniques have been described to facilitate morphology as well as surgical interactions in real time.11–
the creation of a continuous curvilinear capsulorhexis, 13
in-cluding staining the anterior lens capsule with trypan Various classification systems have been proposed for
blue dye to improve visualization, use of high-molecular- senile white cataracts based on the preoperative slitlamp
weight ophthalmic viscosurgical devices (OVDs), use of biomicroscopy, ultrasonographic features, and intra-
forceps, needle puncture, aspiration of the liquefied operative findings.1,14,15 However, these classifications
cortex, bi-manual irrigation/aspiration (I/A), or creation have wide variability and do not integrate the ultrastructural
of femto-second laser morphological features with the intraoperative dynamics
capsulotomies.3–8 Intraoperative optical coherence and capsulorhexis difficulties. Here, the intraoperative
tomography (iOCT) has helped understand intraoperative dynamics and of
dynamics is white cataracts was evaluated with

Submitted: August 23, 2019 | Final review submitted: November 13, 2019 | Accepted: November 22, 2019
From the Cornea, Cataract & Refractive Surgery Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
Corresponding author: Jeewan S. Titiyal, MD, Cornea, Cataract & Refractive Surgery Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Email: titiyal@gmail.com.

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Published by Wolters Kluwer Health, Inc. https://doi.org/10.1097/j.jcrs.0000000000000086

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IOCT-GUIDED MANAGEMENT OF WHITE CATARACT 599

microscope-integrated iOCT, and a new comprehensive classification system
was proposed, including the management strategy based on the real-time
intraoperative characteristics.
METHODS A
prospective interventional study of 50 eyes with white cataract was performed
at a tertiary care ophthalmic center. The study was approved by the institute
ethics committee. Written informed consent was obtained from all patients,
and the study adhered to the tenets of the Declaration of Helsinki.
incisions were hydrated with a balanced salt solution. Post-operatively, all
cases received topical antibiotics and steroids for 1 month and topical
cycloplegics for 2 weeks.
The primary outcome measure was the classification of white cataract
based on morphology, ILP, and intraoperative dynamics assessed using
iOCT. The secondary outcome measure was the presence of any
capsulorhexis-related complications. Post-operative comprehensive
examination included uncorrected and corrected distance visual acuities,
intraocular pressure, slitlamp biomicroscopy, and fundus evaluation. Follow-
up was performed on postoperative day 1 and 1 month.

Patients with senile white cataract planned for phacoemulsi-fication

were prospectively enrolled in this study. Cataracts with total opacification RESULTS
of the lens cortex leading to a white-colored total cataract appearance on Fifty eyes with white cataract were evaluated. The mean age of the patients
the slitlamp were included. Patients with posttraumatic, juvenile, was 63.8 ± 8.3 years (range 47 to 81 years).
complicated white cataract and advanced hypermature cataract with a
Certain morphological features were observed on iOCT in different types of
fibrotic and shrunken anterior lens capsule were excluded. Patients with
any ocular comorbidities and previous ocular surgeries were excluded. white cataract (Figures 1 to 7). Convexity of the anterior lens capsule and its
behavior after OVD injection (relative flattening) or initiation of capsulorhexis
Preoperative comprehensive examination was performed, including (flattening/increased convexity/concave configuration) were observed on
uncorrected distance visual acuity, intraocular pressure, biometry for iOCT. Three predominant features were observed in the anterior lens cortex
intraocular lens power calculation, and B-scan ul-trasonography for
on the iOCT-regular lamellar arrangement of cortical fibers with minimal in-
subsequent segment evaluation.
All surgeries were performed by a single surgeon experienced in tralenticular spaces/clefts, intensely hyperreflective con-tinuous cortical fiber
phacoemulsification (JST). Clear corneal phacoemulsification was performed bands with hyporeflective intralenticular clefts signifying swollen disorganized
through a 2.2 mm temporal clear corneal incision, and an integrated fibers with raised ILP, or homogenous ground-glass appearance signifying
microscope with iOCT (OPMI Lumera 700 and RESCAN 700) was used to confluent cortical liquefaction. The posterior lens capsule could not be
assess the anterior segment and lens architecture throughout the surgery.
adequately assessed using iOCT in any
Real-time anterior segment characteristics and tissue–instrument interactions
were observed
and noted, including the lens morphological features before initiation of
capsulorhexis and anterior segment dynamics on initiation of capsulorhexis.
The anterior lens capsule was stained with trypan blue 0.06% (VisionBlue, case.
DORC International) in all cases after making the corneal incisions.
White cataract was classified into 4 types based on the presence of
Capsulorhexis was initiated with a 26-gauge bent needle cystotome under
a cohesive OVD through the paracentesis incision and completed using a different morphological features on iOCT and intraoperative dynamics on
microforceps or needle cystotome based on the intraoperative initiation of capsulorhexis (Figures 1 to 7 and Table 1).
characteristics. A bimanual I/A of the cortical material was performed in
cases with an imminent risk of capsulorhexis ex-tension after performing
an initial small capsulorhexis. Difficulties in capsulorhexis were subjectively Type I
assessed by the operating surgeon based on the surgeon control over the
Type I white cataract is characterized by regularly arranged lamellar cortical
size and circularity of the rhexis while performing the anterior capsular flap
fibers with minimal intralenticular clefts and without increased convexity of
tear.
the anterior lens capsule (Figure 1, A). Uniform flattening of the anterior lens
Gentle hydrodissection was performed after completion of cap-sulorhexis, capsule was observed on injecting a cohesive OVD. On initiation of
and aggressive nuclear rotation was avoided. Nuclear emulsification was
capsulorhexis, there was no release of turbid or milky fluid. A minimal
performed using phacoemulsification with active fluidics (CENTURION
disturbance of the underlying cortex was observed during capsulorhexis
Vision System, Alcon Laboratories, Inc.), followed by I/A to remove the
residual cortical matter if any. without any bulge of the
A foldable intraocular lens was implanted in the bag, and corneal

Figure 1. Morphological features of type I white cataract on intraoperative optical coherence tomography. A: Regularly arranged lamellar
cortical fibers (yellow arrows) with minimal intralenticular clefts and without increased convexity of the anterior lens capsule. B: On initiation of
capsulorhexis, there was no release of turbid or milky fluid with minimal disturbance of the underlying cortex.

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600 IOCT-GUIDED MANAGEMENT OF WHITE CATARACT

Figure 2. Morphological features of type II white cataract on iOCT. A: Visibly increased convexity of the anterior lens capsule, continuous
hyperreflective bands/sheets of cortical fibers beneath the anterior lens capsule (white arrows) with multiple intralenticular clefts (yellow arrows).
B: On initiation of capsulorhexis, a bulge of the anterior lens cortex into the anterior chamber was observed on iOCT, signifying raised
intralenticular pressure (yellow arrows) (iOCT = intraoperative optical coherence tomography).

Figure 3. Intraoperative OCT–guided bimanual

irrigation/aspiration in type II white cataract to
relieve the cortical bulge. A: Intraoperative OCT–
guided bimanual irrigation/aspiration performed
to relieve the cortical bulge. B: Flattening of the
anterior lens capsule observed after aspirating
the cortical matter. C: Sub-sequent capsulorhexis
successfully completed using a microforceps
(OCT = optical coherence tomography).

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IOCT-GUIDED MANAGEMENT OF WHITE CATARACT 601

Figure 4. Morphological features of type III white cataract on iOCT. A: Convex anterior lens capsule, hyperreflective bands of swollen cortical
fibers (white arrows), intralenticular clefts (yellow arrows), and regions of homogenous ground-glass appearance (red arrows). B: On initiation
of capsulorhexis, there is a release of oily/turbid fluid (yellow arrows) with a simultaneous flattening of the anterior lens capsule seen on iOCT
(iOCT = intraoperative optical coherence tomography).

cortical matter in the anterior chamber (AC), and there was
no additional risk of capsulorhexis extension (Figure 1, B).
A single-stage continuous curvilinear capsulorhexis could be
completed in all cases.
Type II
Type II white cataract is characterized by a visibly increased
convexity of the anterior lens capsule and continuous hy-
perreflective bands/sheets of cortical fibers beneath the
anterior lens capsule with multiple intralenticular clefts (Figure
2, A). The intensely hyperreflective bands mean hydrated
swollen sheets of cortical fibers. The hyporeflective
intralenticular clefts are formed because of the separation of
swollen cortical fibers and a loss of the regular lamellar
arrangement of the cortex. These clefts may contain localized
liquefied cortical material; However, confluent fluid pockets
were not seen on iOCT. On initiation of capsulorhexis, a
release of turbid or milky fluid was not observed. A bulge of
the anterior lens cortex into the AC was observed on iOCT,
signifying raised ILP (Figure 2, B). The continuous hydrated
cortical fibers forming the anterior limit of the cortical bulge
prevented the release of any liquefied cortical material and
subsequent lowering of ILP. The anterior lens capsule also
bowed into the AC along the configuration of the cortical
bulge, resulting in an imminent risk of capsulorhexis ex-
tension. The capsulorhexis nick was converted into a small
circular opening with a microforceps under the cushion of a
dispersive OVD, and an iOCT-guided bimanual I/A was
performed to relief the raised ILP (Figure 3, A). A flattening of
the anterior lens capsule was observed after aspirating the
cortical matter (Figure 3, B). Subsequent capsulorhexis was
successfully completed using a microforceps (Figure 3, C,
Video 1, Supplemental Digital Content 1, available at http://
links.lww.com/JRS/A18 ).
Type III
Type III white cataract is characterized by a convex anterior
lens capsule, hyperreflective bands of swollen cortical fi-
bers, intralenticular clefts, and regions of homogenous ground-
glass appearance (Figure 4, A). The hyperreflective bands
with intralenticular clefts indicate the presence of hydrated
intumescent cortical fibers and subsequent raised ILP,
whereas the homogenous ground-glass regions in-dicate
confluent areas of the liquefied cortical matter. The continuity
of hydrated cortical fiber bands is broken by regions of ground-
glass appearance (fluid).
On initiation of capsulorhexis, there is a release of oily/
turbid fluid, which results in a partial lowering of ILP (Figure
4, B). The turbid fluid egresses spontaneously and slowly
with a simultaneous flattening of the anterior lens capsule
seen on iOCT. The fluid egress may be facilitated by
decompressing the AC through the paracentesis incision. TO

Figure 5. Morphological features of type IV white cataract on intraoperative optical coherence tomography. A: Convex anterior lens capsule
and a uniform homogenous ground-glass appearance of the anterior lens cortex. B: Rapid egress of copious amounts of white milky fluid
(yellow arrows) on initiation of capsulorhexis with flattening of the anterior lens capsule.

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602 IOCT-GUIDED MANAGEMENT OF WHITE CATARACT
Figure 6. Intraoperative optical coherence tomography–guided classification of white cataracts and morphological variations in 4 types of white cataracts.
bimanual I/A or needle aspiration of the fluid may be performed,
although it is not mandatory. There is no well-defined bulge of the
anterior lens cortex in the AC. Slight intumescence of cortical fibers
persisted because of the hyperreflective cortical fiber chords with
intralenticular clefts, and a forceps-assisted rhexis is preferred to
avoid inadvertent capsulorhexis extension. Spiral capsulorhexis and
2-stage capsulorhexis should be performed to allow a controlled
creation of capsulorhexis in these types of
cataract
Type IV
Type IV white cataract is characterized by a convex anterior lens
capsule and a uniform homogenous ground-glass appearance of the
anterior lens cortex, signifying conflu-ent liquefaction of the entire
anterior lens cortex (Figures 5, A and 7, A). Few cortical fibers with
intralenticular clefts may be observed beneath the homogenous
ground-glass region. There is a rapid egress of copious amounts of
white milky fluid on initiation of capsulorhexis with a complete lowering
of ILP (Figures 5, B and 7, B). The convex anterior lens capsule
flattens after the fluid release as observed on iOCT and assumes a
flat to a concave configuration (Figure 7, C). Forceps-assisted
capsulorhexis is performed, with low-moderate difficulty during
capsulorhexis due to a loss of adequate cortical support.
In this series, type I cataract was observed in 9 (18%) of 50 eyes,
type II in 3 (6%) of 50 eyes, type III in 24 (48%) of 50 eyes, and type
IV in 14 (28 %) of 50 eyes. No case had radial extension of
capsulorhexis or capsular tears. A continuous curvilinear capsulorhexis
was achieved in all
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cases. A bimanual I/A was performed in all 3 eyes with type II cataract
and 4 eyes with type III cataract, followed by completion of
capsulorhexis with a forceps. Phacoe-mulsification could be
completed uneventfully in all cases, and there was no case with
posterior capsular tear or vitreous loss. At 1 month, the uncorrected
distance visual acuity was 20/25 or better in all cases.
DISCUSSION
White cataracts continue to pose a surgical challenge even for
experienced surgeons, with continuous curvilinear capsulorhexis
being the most difficult surgical step. An incomplete capsulorhexis
may be observed in 3.85% to 28.3% of cases, with an increased
incidence of posterior capsular rupture and vitreous loss.4,16
We describe a new iOCT-based classification of white cataracts
and correlated the morphological features with the intraoperative
difficulty during capsulorhexis. We also proposed management
strategies based on the type of white cataract and intraoperative
dynamics.
The previous classification systems of white cataract are based on
the preoperative slitlamp biomicroscopy or ul-trastructural
features.1,14,15 Raised ILP has been universally recognized as
causing difficulties during capsulorhexis; however, it is usually
described in association with egress of milky fluid.1,14,15 Brazitikos
et al. classified white cataract into 3 types based on ultrasonographic
features, with type I characterized by intumescent cataract with fluid
egress on initiation of capsulorhexis, type II as a nonintumescent
voluminous nucleus, and type III with a fibrosed capsule and hard
sclerotic nucleus.1 Basti classified white cataract based
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IOCT-GUIDED MANAGEMENT OF WHITE CATARACT
on slitlamp biomicroscopy features into 8 subtypes based
on ILP (assessed by convexity of the anterior lens
capsule), status of the cortex, and color of the nucleus.14
Dhami et al. used anterior segment OCT to assess the
presence or absence of intralenticular
subcapsular fluid pockets.15 We observed that type II
intumescent cataract with raised ILP is not associated with
any fluid release. The classic Argentinian flag sign is most
likely to be observed in this type of cataract, and an urgent
decompression of the ILP is essential to prevent
capsulorhexis extension.17 By contrast, fluid release helps
relieve the raised ILP either partially (type III) or completely
(type IV). In type III cataract, the ILP, although not as
raised as in type II cataract, still causes difficulty during
capsulorhexis, and a forceps-assisted rhexis provides
more surgeon control for successful completion of capsulorhexis.gauge
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603
Figure 7. Morgagnian type of hypermature white
cataract observed on intraoperative optical
coherence tomography. A: Convex anterior lens
capsule and a uniform homogenous ground-
glass appearance of the anterior lens cortex. B:
Rapid egress of copious amounts of white milky
fluid on initiation of capsulorhexis. C: Concave
anterior lens capsule configuration (yellow ar-
rows) with empty space between the capsule and
the nucleus (white arrows) visualized after release
of the milky fluid.
matter may be required in some cases to reduce the
persistent intumescence. Type IV cataract is associated
with copious release of white milky fluid with complete
reso-lution of ILP, and the main difficulty in capsulorhexis
in these types of white cataract stems from a lack of
cortical support during rhexis rather than a raised ILP.
Morgagnian cataract (liquified cortex with sclerotic nucleus)
is a type IV white cataract, and a concave anterior lens
capsule con-figuration with empty space between the
capsule and the nucleus can be visualized after release of
the milky fluid (Figure 7).
A sudden explosive egress of milky fluid in type IV cat-
aracts may still result in capsulorhexis extension if a large
initial opening in the anterior lens capsule is made. We
made an initial small nick (akin to a puncture) with a 26-
A bimanual
needleI/A of the cortical
cystotome through the paracentesis incision under
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604 IOCT-GUIDED MANAGEMENT OF WHITE CATARACT

Table 1. Intraoperative OCT–based classification and management of senile white cataract.

Characteristics Type I Type II Type III Type IV

Morphological features
Raised ILP preoperatively
Regularly arranged lamellar
cortical fibers with minimal
intralenticular clefts
No
Increased convexity of the
previous lens capsule and
continuous hyperreflective
bands of swollen cortical
fibers with intralenticular
clefts
Forks
Combination of hyperreflective
cortical bands with
intralenticular clefts and
regions of homogenous
ground-glass appearance
Forks
Uniform homogenous
ground-glass appearance
of the anterior lens cortex
Forks

Fluid release on initiation of No No Forks Forks

capsulorhexis
Resolution of ILP after
initiation of capsulorhexis
Risk of capsulorhexis
extension
Management strategy
— No Forks
No (partial resolution)
Low High Moderate Low-moderate
Single-stage forceps/needle Forceps-assisted 2-stage Aspiration of turbid fluid, AC decompression to
cystotome capsulorhexis capsulorhexis. Bimanual needle aspiration, and I/A facilitate egress of milky fluid
I/A to lower ILP after Forceps-assisted and improve visualization
initial small rhexis capsulorhexis Forceps-assisted
capsulorhexis

AC = anterior chamber; I/A = irrigation/aspiration; ILP = intralenticular pressure; OCT = optical coherence tomography

a cohesive OVD cover. This allowed for a controlled egress of
the milky fluid, and we did not observe any capsulorhexis
extension. The cohesive OVD was retained well; moreover, it
allowed space for fluid release.
After initiation of rhexis, a dispersive OVD was injected
over the cohesive OVD in types II to IV white cataract to
complete the rhexis. The cohesive OVD facilitates easy
manipulation of the anterior capsular flap, and the dis-persive
OVD tamponades the flap and does not allow the
cohesive OVD to escape.
We use iOCT as a guide to decision making based on
the assessment of prenick and postnick features. We
progressed with conventional capsulorhexis in type I cat-
aracts without any additional difficulty. It was most difficult
to control the flap tear in type II cataracts because of the
cortical bulge, and all cases required a bimanual I/A fol-
lowed by secondary enlargement of the rhexis. Type III
cataract had some amount of intumescence and positive
pressure even after fluid release; however, the surgeon
control over the flap tear was better than that in type II
cataract In type IV cataract, the main difficulty during flap
tear was due to the absence of cortical support after release
of the fluid cortex.
A needle aspiration of the liquefied cortex may be per-
formed in type III cataracts; however, it is unlikely to be
useful in type II cataracts because of the absence of con-
fluent fluid pockets. The capsulorhexis difficulties were
graded as low in type I, low to moderate in type IV,
moderate in type III, and high in type II cataracts.
We did not observe any anterior capsular tears, rhexis
extension, or posterior capsular rupture in our series. All
surgeries were performed by a single experienced surgeon
(JST). Intraoperative OCT helped us to directly visualize
and assess the dynamics of the anterior lens capsule and
corticonuclear complex and manage the cases accordingly,
which may have helped pre-empt and prevent rhexis-related
complications.
Our classification of white cataract based on iOCT could
have manifold functional advantages. First, iOCT helps
understand the morphology of white cataracts. Second, it
could aid in the understanding of the current intraoperative
dynamics of different types of white cataract and identify
true intumescent cataracts with an imminent risk of cap-
sulorhexis extension. The dynamics of the anterior lens
surface before and after the creation of the initial nick in the
anterior lens capsule, variation in positive lenticular pressure
with different maneuvers, and subsequent completion of
rhexis could be directly visualized. Third, it could help
formulate a management plan based on the morphological
features observed on iOCT to successfully complete the
capsulorhexis. Finally, our classification also demonstrates
the natural progression of white cataract wherein the cortical
fibers progressively become hydrated distorting the normal
lamellar arrangement of the lens cortex, followed by pro-
gressive liquefaction of the cortical material. Type I cataract
had regular lamellar cortical fibers with no fluid or clefts,
type II had hydrated swollen cortical fibers with multiple
intralenticular clefts, type III had cortical liquefaction in-
terspersed with intralenticular clefts, and type IV had ex-
tensive liquefaction of the anterior lens cortex. White
cataracts encompass a wide spectrum of morphological
variants, and there may be a combination of characteristics
and overlap between types, but classically they may be
grouped into 4 types as per our classification (Figure 6).
The use of microscope-integrated iOCT as an aid to
decision making has classically been described in lamellar
keratoplasties and posterior segment surgeries.9,10 For
a cataract surgeon, iOCT may be viewed as an additional
nonessential therapeutic modality. However, we observed
that iOCT helps assess surgical dynamics and is a valuable

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IOCT-GUIDED MANAGEMENT OF WHITE CATARACT
tool to significantly enhance our understanding and predict
intraoperative behavior of different types of white cataract.
In case of unavailability of microscope-integrated iOCT, anterior
segment OCT or hand-held OCT may be used in the preoperative
assessment of these cases based on the presence of intralenticular
clefts and homogenous ground-glass appearance, but the real-time
intraoperative dynamics can only be evaluated using microscope-
integrated iOCT.
The limitations of iOCT include an inability to view the posterior lens
capsule due to dense cataract.
Our classification might be clinically useful because it helps
characterize types of white cataract based on the morphological
characteristics observed on iOCT before starting the surgery and the
behavior of the anterior lens capsule and lens cortex after creating the
initial nick.
Conventionally, spontaneous milky fluid release has been associated
with intumescence and difficult rhexis. By contrast, iOCT helps in the
understanding of that fluid release leads to a relative flattening of the
anterior lens capsule and the rhexis becomes more controlled,
considering intumescent cataracts with a bulging cortex, sustained
high positive pressure, and an imminent risk of rhexis extension are
not associated with spontaneous fluid release. Intra-operative OCT
helps understand the real-time intra-operative dynamics in the
spectrum of white cataracts and facilitates the creation of a more
controlled continuous curvilinear capsulorhexis in these cases.
WHAT WAS KNOWN
Senile white cataracts may be classified based on the preoperative slitlamp
biomicroscopy or ultrasonographic features.
Intumescent cataract with egress of milky fluid on in-itiation of capsulorhexis
is associated with rhexis-related complications.
WHAT THIS PAPER ADDS
Intraoperative optical coherence tomography (OCT) helps comprehensively
classify white cataracts based on the morphological characteristics and
in any material or method mentioned.
intraoperative dynamics of the anterior lens capsule and lens cortex after
creating the
initial nickname
Not all intumescent cataracts (type II) are associated with fluid release.
Milky fluid egress leads to a partial (type III) or complete (type IV) lowering
of intralenticular pressure.
Intraoperative OCT–guided management helps create a more controlled
continuous curvilinear capsulorhexis in different types of white cataract.
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605
REFERENCES
1. Brazitikos PD, Tsinopoulos IT, Papadopoulos NT, Fotiadis K, Stangos NT.
Ultrasonographic classification and phacoemulsification of white senile cataracts.
Ophthalmology 1999;106:2178–2183
2. Pandey SK, Werner L, Escobar-Gomez M, Roig-Melo EA, Apple DJ. Dye-enhanced cataract
surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract. J
Cataract Refract Surg 2000;26:1052–1059 3. Bhattacharjee K, Bhattacharjee H, Goswami
BJ, Sarma P. Capsulorhexis in intumescent cataract. J Cataract Refract Surg 1999;25:1045–1047
4. Jacob S, Agarwal A, Agarwal A, Agarwal S, Chowdhary S, Chowdhary R, Bagmar
AA. Trypan blue as an adjunct for safe phacoemulsification in eyes with white cataract. J Cataract
Refract Surg 2002;28:1819–1825 5. Kara-Junior N, de Santhiago MR, Kawakami A,
Carricondo P, Hida WT.
Mini-rhexis for white intumescent cataracts. Clinics 2009;64:309–312 6. Vajpayee RB,
Bansal A, Sharma N, Dada T, Dada VK. Phacoemulsification of white hypermature cataract. J
Cataract Refract Surg 1999;25:1157–1160 7. Figueiredo CG, Figueiredo J, Figueiredo GB.
Brazilian technique for pre-vention of the Argentinean flag sign in white cataract. J Cataract
Refract Surg 2012;38:1531–1536
8. Titiyal JS, Kaur M, Singh A, Arora T, Sharma N. Comparative evaluation of femtosecond laser-
assisted cataract surgery and conventional phacoemul-sification in white cataract. Clin
Ophthalmol 2016;10:1357–1364 9. Ehlers JP, Dupps WJ, Kaiser PK, Goshe J,
Singh RP, Petkovsek D, Srivastava SK. The prospective intraoperative and perioperative
ophthalmic ImagiNg with optical CoherEncE TomogRaphy (PIONEER) study: 2-year results.
Am J Ophthalmol 2014;158:999–1007 10. Ehlers JP, Goshe J, Dupps WJ, Kaiser PK, Singh
RP, Gans R, Eisengart J, Srivastava SK. Determination of
feasibility and utility of microscope-integrated optical coherence tomography during ophthalmic
surgery: the DISCOVER Study RESCAN Results. JAMA Ophthalmol 2015;133:1124–1132
11. Titiyal JS, Kaur M, Ramesh P, Shah P, Falera R, Bageshwar LMS, Kinkar A, Sharma N. Impact
of clear corneal incision morphology on incision-site Descemet membrane detachment in
conventional and femtosecond laser-assisted phacoemulsification. Curr Eye Res 2018;43:293–
299 12. Titiyal JS, Kaur M, Sahu S, Sharma N, Sinha R. Real-time assessment
of intraoperative vaulting in implantable collamer lens and correlation with postoperative vaulting.
Eur J Ophthalmol 2017;27:21–25 13. Titiyal JS, Kaur M, Falera R. Intraoperative optical
coherence tomography in anterior segment surgeries. Indian J
Ophthalmol 2017;65:116–121 14. Basti S. Different faces of the white cataract: a phaco surgeon's
perspec-tive. Aust NZJ Ophthalmol 1999;27:53–56
15. Dhami A, Dhami AS, Singh H, Dhami GS. Role of anterior segment optical coherence
tomography for safer management of mature white cataracts.
J Cataract Refract Surg 2019;45:480–484
16. Chakrabarti A, Singh S. Phacoemulsification in eyes with white cataract.
J Cataract Refract Surg 2000;26:1041–1047 17. Perrone
D, Albertazzi R. “Argentina flag sign,” Video J Cataract Refract Surg. 2001;17:1
Disclosures: None of the authors has a financial or proprietary interest
First author:
Jeewan S. Titiyal, MD
Cornea, Cataract & Refractive Surgery Services,
Dr. Rajendra Prasad Center for Ophthalmic
Sciences, All India Institute of Medical Sciences,
New Delhi, India
Volume 46 Issue 4 April 2020