UNASSIGNED: We describe an alternative automated technique that consists of simultaneous anterior capsule puncture and decompression of the capsular bag by using an insulin needle attached to the aspiration tubing of the phacoemulsification device to prevent the occurrence of the \"Argentinian Flag sign\" during capsulorhexis in intumescent cataract.
UNASSIGNED: Instituto de Olhos de Assis and Center of Specialties Hoftalmed, located in the state of São Paulo, Brazil.
UNASSIGNED: Prospective interventional study.
UNASSIGNED: Eighty-eight eyes of 88 patients with white or intumescent cataracts were included in this study. Routine clear cornea incision, capsule staining with trypan blue, intracameral anesthesia, and ophthalmic viscoelastic device were used before the procedure. A 26-gauge needle was connected to the phacoemulsification aspiration tubing using a double male Luer connector for irrigation, and aspiration was inserted into the anterior chamber through a new paracentesis incision with the bevel facing down. Immediately after insertion, automated aspiration of the liquefied cortex was performed to remove anterior intralenticular material and achieve capsular decompression. Compression of the nucleus with the needle tip was performed to remove any liquefied material trapped between the posterior surface of the nucleus and the posterior capsule. All surgeries were performed using the same phacoemulsification and parameters. The rate of complete continuous capsulorhexis was observed and noted.
UNASSIGNED: No complications were observed in any of the cases. A single-stage, continuous, and well-centered capsulorhexis was achieved in 100% of cases.
UNASSIGNED: We conclude that a simultaneous puncture and decompression of the capsular bag using an insulin needle attached to the aspiration tubing of the phacoemulsification machine effectively avoided the \"Argentinian Flag sign\" in intumescent cataract surgery.

OBJECTIVE: This study evaluates the accuracy of modern intraocular lens (IOL) calculation formulas using axial length (AL) data obtained by ultrasound biometry (UBM) compared to the third-generation SRK/T calculator.
METHODS: The study included 230 patients (267 eyes) with severe lens opacities that prevented optical biometry, who underwent phacoemulsification (PE) with IOL implantation. IOL power calculation according to the SRK/T formula was based on AL and anterior chamber depth obtained by UBM (Tomey Biometer Al-100) and keratometry on the Topcon KR 8800 autorefractometer. To adapt AL for new generation calculators - Barrett Universal II (BUII), Hill RBF ver. 3.0 (RBF), Kane and Ladas Super Formula (LSF) - the retinal thickness (0.20 mm) was added to the axial length determined by UBM, and then the optical power of the artificial lens was calculated. The mean error and its modulus value were used as criteria for the accuracy of IOL calculation.
RESULTS: A significant difference (p=0.008) in the mean IOL calculation error was found between the formulas. Pairwise analysis revealed differences between SRK/T (-0.32±0.58 D) and other formulas - BUII (-0.16±0.52 D; p=0.014), RBF (-0.17±0.51 D; p=0.024), Kane (-0.17±0.52 D; p=0.029), but not with the LSF calculator (-0.19±0.53 D; p=0.071). No significant differences between the formulas were found in terms of mean error modulus (p=0.238). New generation calculators showed a more frequent success in hitting target refraction (within ±1.00 D in more than 95% of cases) than the SRK/T formula (86%).
CONCLUSIONS: The proposed method of adding 0.20 mm to the AL determined by UBM allows using this parameter in modern IOL calculation formulas and improving the refractive results of PE, especially in eyes with non-standard anterior segment structure.
UNASSIGNED: Оценка точности современных формул расчета интраокулярных линз (ИОЛ) с использованием данных о длине переднезадней оси (ПЗО), полученных при ультразвуковой биометрии (УЗБ), по сравнению с калькулятором третьего поколения SRK/T.
UNASSIGNED: В исследование включено 230 пациентов (267 глаз) с выраженными помутнениями хрусталика, препятствовавшими выполнению оптической биометрии, которым была проведена факоэмульсификация (ФЭ) с имплантацией ИОЛ. Калькуляция оптической силы ИОЛ по формуле SRK/T основывалась на длине ПЗО и глубине передней камеры, полученных с помощью контактной УЗБ (Tomey Biometer Al-100) и кератометрии на авторефрактокератометре Topcon KR 8800. В целях адаптации ПЗО для калькуляторов нового поколения — Barrett Universal II (BUII), Hill RBF ver. 3.0 (RBF), Kane и Ladas Super Formula (LSF) — к определяемой с помощью УЗБ аксиальной длине добавлялась толщина сетчатки (0,20 мм), а затем вычислялась оптическая сила искусственного хрусталика. В качестве критериев точности расчета ИОЛ использовались средняя ошибка и модуль ее значения.
UNASSIGNED: Обнаружена значимая разница (p=0,008) в средней ошибке расчета ИОЛ между формулами. Попарный анализ выявил различия между SRK/T (–0,32±0,58 дптр) и другими формулами — BUII (–0,16±0,52 дптр; p=0,014), RBF (–0,17±0,51 дптр; p=0,024), Kane (–0,17±0,52 дптр; p=0,029), но не с калькулятором LSF (–0,19±0,53 дптр; p=0,071). Значимых различий между формулами по параметру модуля средней ошибки найдено не было (p=0,238). Калькуляторы новых поколений показали более частое попадание в рефракцию цели (в пределах ±1,00 дптр более чем в 95% случаев), чем формула SRK/T (86%).
UNASSIGNED: Предложенный метод добавления 0,20 мм к определяемой с помощью УЗБ длине ПЗО позволяет использовать данный параметр в современных формулах расчета ИОЛ и улучшать рефракционные результаты ФЭ, особенно в глазах с нестандартным строением переднего отрезка.

UNASSIGNED: The aim of this study was to develop a modified capsulorhexis technique featuring a new maneuver for the removal of subcortical fluid in fluid-filled mature cataracts to avoid high intralenticular pressure.
UNASSIGNED: This prospective interventional study included 33 eyes with mature cataracts and evidence of subcapsular fluid spaces by slit lamp examination. For each patient, 20% mannitol was administered intravenously according to the bodyweight 1 h preoperatively. Under peribulbar anesthesia, a 2.2-mm main incision was made, and the anterior chamber was filled with a dispersive ophthalmic viscosurgical device. Using a bent-tip cystotome, a 2-mm curved incision was made in the center of the anterior capsule, which released subcortical fluid and was drained through compression of the posterior lip of the main incision using a spatula. Then, fine gentle milking in all quadrants around the puncture on the anterior lens capsule from the periphery toward the site of puncture using the blunt-edged spatula further assists drainage of subcortical fluid and breaks fine septa inside the lens to remove fluid from intralenticular fluid pocket collections.
UNASSIGNED: The study included 15 (45.5%) men and 18 (54.5%) women with a mean (standard deviation [SD]) of age of 63.2 (5.33) and 64.4 (6.21) years, respectively. The modified capsulorhexis technique was performed for 33 intumescent cataracts. Capsulorhexis was completed in all cases; capsulorhexis was easy in 31 (94%) eyes and difficult in 2 (6%) eyes. In the two difficult cases, radial extension occurred in one eye, and it was retrieved using the Little technique; the other case with radial tear was completed successfully using a retinal micro scissor from the other edge of the capsulorhexis until reaching an oval, continuous capsulorhexis.
UNASSIGNED: This modified capsulorhexis technique with compression on the posterior lip of the main incision and capsule milking allowed for a safe, continuous curvilinear capsulorhexis. Further comparative studies are necessary to confirm our preliminary results.

A capsulorhexis technique with a 23-gauge vitreous cutter in intumescent cataract surgery is presented. These patients have a high risk of uncontrollable extension of the opening of the anterior lens capsule. We used vitreous cutter for capsulorhexis along with the other steps performed as in standard phacoemulsification surgery. This technique allows controlled capsulorhexis and may be an alternative method in patients with intumescent cataracts with high intralenticular pressure and absence of red reflex.

BACKGROUND: Capsulorhexis is the most important step in intumescent cataract due to the high risk of radial extension of the capsular tear during the cataract surgery. The aim of this study is to present modified the two-stage capsulorhexis technique for intumescent cataract.
METHODS: The two-stage capsulorhexis technique was used in this study. A small size capsulorhexis approximately 1.5-2 mm diameter was created in the first stage. Liquefied cortex was aspirated with a 25 G cannula to equalize anterior chamber pressure and intracapsular pressure after the small size capsulorhexis. In the second stage, a 5-6 mm capsulorhexis size was performed for a safe phacoemulsification.
RESULTS: A total of 73 consecutive patients with intumescent cataract were evaluated in this study. There were 39 male cases and 34 female cases. Mean age was 66 years ± 8 (between 53 and 84 years). A well centered complete continuous curvilinear capsulorhexis approximately 5-6 mm size was achieved in 72 of 73 cases (98.6%). Peripheral extension of capsulorhexis occurred in one eye during the second stage capsulorhexis. In this case, the capsule was cut with Vannas scissors and the capsulorhexis was completed. The rest of surgery was continued with a standard procedure and in-the-bag IOL implantation was done.
CONCLUSIONS: This technique facilitates the creation of a safe capsulorhexis compared to the one-stage capsulorhexis technique. Surgeons may consider this technique to perform a safe phacoemulsification in the intumescent cataracts.

OBJECTIVE: To evaluate the efficacy of technique combining an anterior chamber maintainer (ACM) and spiral capsulorhexis under continuous fluid pressure in intumescent cataracts.
METHODS: One hundred thirty-one eyes of 128 patients who underwent phacoemulsification and IOL implantation for intumescent white cataracts without a red reflex were included in the study. Group 1 consisted of 67 eyes of 65 patients who underwent spiral capsulorhexis with an ACM under continuous fluid pressure. Group 2 consisted of 64 eyes of 63 patients who underwent capsulorhexis after injection of viscoelastic material into the anterior chamber. Both groups were compared in terms of endothelial cell loss, intraoperative and postoperative complications.
RESULTS: Progression to the periphery in the capsule not resulting in a radial tear was observed in 3 eyes in Group 1 and 11 eyes in Group 2 (P=0.019). While the type of radial tear known as the Argentinian flag sign was not observed in Group 1, it was observed in 8 eyes in Group 2 (P=0.003). Postoperative intraocular lens (IOL) decentration did not develop in any eye in group 1, but in 3 eyes in group 2 (P=0.11).
CONCLUSIONS: The combination technique of an anterior chamber maintainer and spiral capsulorhexis provides a controlled and safe capsulorhexis and reduces intraoperative and postoperative complications in intumescent cataracts.

Achieving a complete uniform capsulorhexis in an intumescent cataract is perhaps the most crucial and challenging step for surgeons. Star CanVac CCC is a new manual technique for creating a continuous curvilinear capsulorhexis (CCC) in intumescent total cataracts. Small centripetal tears in the shape of a star are created in the center of the anterior lens capsule by using a 26-G cystotome. This allows equal distribution of forces secondary to increased intralenticular pressure, thereby avoiding unidirectional or bidirectional tear extension. Subsequently, a 25-G flat-tipped fine cannula connected to a syringe is used to hold the free capsular flap. The piston of the syringe is withdrawn to create a stable suction pressure, and the rhexis is completed without withdrawing the instrument from the anterior chamber. Our technique is safe, affordable, and an alternative method to routine CCC or expensive techniques such as Femto or Zepto capsulotomy for white intumescent cataracts.

OBJECTIVE: To optimize the technique of intumescent cataract phacoemulsification by involving the use of femtosecond lasers.
METHODS: Group 1 included 29 patients (30 eyes) with mature intumescent cataract, who underwent femtolaser-assisted phacoemulsification using a new, optimized technique. Group 2 included 20 patients (20 eyes), in whom the femtolaser stage was performed using the standard technique. Patients of groups 1 and 2 were almost identical in all preoperative parameters. The optimized femto-capsulorhexis technique included: preoperative assessment of intralenticular pressure, staining of the anterior capsule of the swelling lens with trypan blue, introduction of a viscoelastic with high molecular weight into the anterior chamber to balance intraocular and intralenticular pressures, increasing the laser energy when performing anterior capsulorhexis up to 10 mJ.
RESULTS: In group 1, there was a non-penetration of the anterior capsule in 2 eyes, in one of them in the 30° sector, in the second - in the 45° sector. Leakage of lens material into the anterior chamber and the floating anterior capsule were not observed in patients of group 1. In group 2, non-penetration of the anterior capsule was observed in 6 eyes, in the 45-60° sector - in 2 eyes, in the 90° sector - in 3 eyes, in the 180° sector - in 1 eye. Floating anterior capsule was observed in 5 cases. Leakage of lens material into the anterior chamber was observed in 9 eyes.
CONCLUSIONS: The optimized technique of femtolaser-assisted intumescent cataract phacoemulsification eliminates leakage of lens material into the anterior chamber and allows performing anterior capsulorhexis of given size and shape.
UNASSIGNED: Оптимизировать технологию факоэмульсификации набухающей катаракты с использованием фемтолазерного сопровождения.
UNASSIGNED: В 1-ю группу вошли 29 пациентов (30 глаз) с набухающей зрелой катарактой, у которых фемтолазерное сопровождение выполнялось по новой, оптимизированной технологии. Во 2-ю группу были включены 20 пациентов (20 глаз), у которых этап фемтолазерного сопровождения проводился по стандартной технологии. По всем дооперационным параметрам пациенты обеих групп были практически идентичны. Оптимизированная технология фемтокапсулорексиса включала в себя предоперационную оценку внутрихрусталикового давления, окрашивание передней капсулы набухающего хрусталика трипановым синим, введение в переднюю камеру высокомолекулярного вискоэластика для уравновешивания внутриглазного и внутрихрусталикового давления, повышение энергии лазера при выполнении переднего капсулорексиса до 10 мкДж.
UNASSIGNED: В 1-й группе в двух глазах наблюдалось непросечение передней капсулы (в одном глазу в секторе 30°, во втором — в секторе 45°). Выход хрусталиковых масс в переднюю камеру и флоттирующая передняя капсула у пациентов 1-й группы не наблюдались. Во 2-й группе непросечение передней капсулы наблюдалось в шести глазах, в том числе в секторе 45—60° — в двух, в секторе 90° — в трех, в секторе 180° — в одном глазу. Флоттирующая передняя капсула выявлена в пяти случаях. Выход хрусталиковых масс в переднюю камеру наблюдался в девяти глазах.
UNASSIGNED: Оптимизированная технология фемтолазерного сопровождения факоэмульсификации набухающей катаракты исключает выход хрусталиковых масс в переднюю камеру и позволяет сформировать передний капсулорексис заданных размеров и формы.

To present a case series of intumescent white cataract cases managed by a new surgical technique to attain a single stage Continuous Curvilinear Capsulorhexis (CCC).
The series included 60 eyes of 60 patients with white cataract which underwent preoperative anterior chamber depth, lens thickness and ultrasonographic A-scan for intralenticular spikes. A partial size main port (~1.8mm) is created as the first entry into the anterior chamber (AC). A 30-gauge needle of insulin syringe entered through a limbal stab incision is used to decompress the anterior and posterior intralenticular compartments. Following which a standard size, one stage capsulorhexis was performed in a trypan blue stained capsule using microcapsulorhexis forceps entered through the partial sized trapezoidal main port. The main port was secondarily enlarged for phacoemulsification.
Based on the intraoperative findings, 43 eyes were categorized as Intumescent type-1 cataracts i.e., with presence of actual liquefied cortex aspirated using 30-gauge needle and 17 eyes as Intumescent type-2 cataracts, i.e., presence of swollen lens without any obvious liquefied cortex. Standard size, circular and centred CCC was achieved in 100% of the cases and no Argentinean flag sign was noted. Surgeon perceived raised intralenticular pressure in 41% of the cases in type-1 subset and 61% cases in type-2 subset (P-0.06). Posterior capsular plaque was observed in 22% of the cases, adherent cortex in 25% and anterior capsular plaque in 5% of the cases. At 6weeks follow up 92% patients had best corrected visual acuity of 20/40 or better.
A multi-layered approach can help in attaining successful CCC in cases of white mature cataract with high intralenticular pressure.

We report a rare case of bilateral keratoglobus with hypermature intumescent cataract in a 55-year-old woman. Clinical examination and corneal topography confirmed generalized corneal bulging and global corneal thinning. A Pentacam® (Oculus Optikgerate, Wetzlar, Germany) demonstrated bilateral diffuse corneal thinning (368 μm in the right eye and 371 μm in the left eye). Phacoemulsification was performed in the right eye after thorough workup and modification of the surgical technique. This case report helps in better understanding of the challenges of cataract surgery and intraocular lens selection in a keratoglobus patient, and stresses the need for both thorough preoperative planning and intraoperative surgical modifications.