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“White-puncture”: A simple technique to prevent tearing of the anterior capsule during capsulorhexis in intumescent white cataracts
Blancopunción: una técnica simple para prevenir el desgarro de la cápsula anterior durante la capsulorrexis en cataratas blancas intumescentes
A. Blancoa, C. Rocha-de-Lossadab,
, P. Navarroc, S.F. Lernerd, L. Perronee, F.L. Soler Ferrándezf
Corresponding author
a Departamento de Oftalmología, Hospital Oftalmológico Santa Ana, Buenos Aires, Argentina
b Departamento de Oftalmología, Hospital Costa del Sol, Marbella, Spain
c Departamento de Oftalmología, Instituto de Oftalmología de Bariloche, Bariloche, Río Negro, Argentina
d Departamento de Oftalmología, Facultad de Ciencias Médicas, Universidad Favaloro, Buenos Aires, Argentina
e Departamento de Oftalmología, Centro de ojos Quilmes, Buenos Aires, Argentina
f Departamento de Oftalmología, Innova Ocular Clínica Dr. Soler, Elche, Alicante, Spain
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Nótese cómo tras puncionar la cámara anterior (CA) con una aguja 30<span class="elsevierStyleHsp" style=""></span>G y, por lo tanto, de un calibre tan fino que la CA se mantiene estanca y sellada. La PIC se equilibra con la PCA y la PCV, permitiendo la liberación controlada del contenido licuado intumescente cristaliniano. c) Escenario en el que se ha realizado una paracentesis o incisión previa y se ha utilizado una mínima cantidad de sustancia oftálmica viscoelástica (OVD). Nótese que aquí hay un desequilibrio de presiones por la pérdida brusca de presión al no existir una CA estanca, que provoca el desgarro capsular anterior (signo de la bandera argentina).</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">d) De forma similar al escenario anterior, pero en este caso con un sobrellenado de la CA con OVD en el intento de aumentar la PCA para equipararla con la PIC. En este escenario, debido a la existencia de la PCV se produce una compresión bilateral del cristalino intumescente mediada por el aumento de PCA y la existencia de la PCV que puede provocar un desgarro a modo de «explosión» de la cápsula anterior. Como ejemplo gráfico, esta situación sería similar a lo que ocurriría si apretásemos con ambas manos un globo lleno de aire; esta presión bilateral podría llegar a originar una explosión del globo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Blanco, C. Rocha-de-Lossada, P. Navarro, S.F. Lerner, L. Perrone, F.L. Soler Ferrández" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Blanco" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Rocha-de-Lossada" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Navarro" ] 3 => array:2 [ "nombre" => "S.F." "apellidos" => "Lerner" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Perrone" ] 5 => array:2 [ "nombre" => "F.L." 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The presence of the lens in the vitreous cavity is evident in both eyes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C.E. Monera Lucas, J. Escolano Serrano, D. Romero Valero, A. Navarro Navarro, J.J. Martínez Toldos" "autores" => array:5 [ 0 => array:2 [ "nombre" => "C.E." "apellidos" => "Monera Lucas" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Escolano Serrano" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Romero Valero" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Navarro Navarro" ] 4 => array:2 [ "nombre" => "J.J." 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Blanco, C. Rocha-de-Lossada, P. Navarro, S.F. Lerner, L. Perrone, F.L. Soler Ferrández" "autores" => array:6 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Blanco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "C." "apellidos" => "Rocha-de-Lossada" "email" => array:1 [ 0 => "carlosrochadelossada5@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Navarro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "S.F." "apellidos" => "Lerner" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "L." "apellidos" => "Perrone" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "F.L." "apellidos" => "Soler Ferrández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departamento de Oftalmología, Hospital Oftalmológico Santa Ana, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Oftalmología, Hospital Costa del Sol, Marbella, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Oftalmología, Instituto de Oftalmología de Bariloche, Bariloche, Río Negro, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Oftalmología, Facultad de Ciencias Médicas, Universidad Favaloro, Buenos Aires, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Oftalmología, Centro de ojos Quilmes, Buenos Aires, Argentina" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Oftalmología, Innova Ocular Clínica Dr. Soler, Elche, Alicante, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Blancopunción: una técnica simple para prevenir el desgarro de la cápsula anterior durante la capsulorrexis en cataratas blancas intumescentes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 492 "Ancho" => 1305 "Tamanyo" => 89669 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a) White-puncture: note how the anterior capsule of a hypermature cataract is punctured as a first surgical step with the help of a 30<span class="elsevierStyleHsp" style=""></span>G needle. b) Anterior capsule opened after the white-puncture and later dyed with trypan blue prior to starting capsulorhexis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypermature, white and intumescent cataracts are still common, especially in developing countries. In this type of cataract, the anterior capsule tends to be thin and fragile.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In summary, we can say that there are 2 types of white cataracts: pearly cataracts, usually with very little or no liquefied cortex, and morganian cataracts with a large amount of liquefied cortex.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Because they are sometimes difficult to differentiate clinically, particularly in supposedly intumescent cataracts with minimal liquefied cortex,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Dhami et al. recently described the use of anterior segment optical coherence tomography as a useful tool for identifying the presence or absence of fluid pockets within the lens in cases of mature and intumescent cataracts, suggesting that it may be helpful for surgical planning.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Phacoemulsification is a challenge in these eyes, particularly during the creation of the continuous circular capsulorhexis (CCC),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> which is often complicated by a usually radial tear of the anterior lens capsule when punctured on an intumescent lens with a high intracrystalline pressure (ICP),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> originating the so-called “Argentinian flag sign”, when it occurs in a surgery where a capsular stain with trypan blue has been used.<a class="elsevierStyleCrossRef" href="#fn0005"><span class="elsevierStyleSup">g</span></a> Occasionally, the tear may subsequently extend beyond the equator, affecting the zonule and posterior capsule, causing the nucleus to fall, the vitreous to be lost and the intraocular lens to shift posteriorly.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous techniques have been published to diminish the complications that usually occur during the creation of CCC in this type of cataract: the use of trypan blue,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 2-step capsulotomy,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the Brazilian technique,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> filling the anterior chamber (AC) with balanced saline solution (BSS) prior to capsular puncture,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the use of ophthalmic viscoelastic substance (OVD) associated with capsular puncture and aspiration of the liquefied content with a fine needle and subsequent lens “milking”,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> preoperative anterior capsulotomy with Nd laser:YAG,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> phaco-capsulotomy<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> or capsulotomy in the context of femtosecond laser-assisted cataract surgery (FLACS)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> among others.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this study is to present a new surgical technique, the so-called white-puncture which the authors believe can avoid in a simple, reproducible and effective way the anterior capsule tear when performing CCC in white, intumescent and hypermature cataracts.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Surgical technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">All surgeries were performed by the same surgeon (AB). The surgical preparation of the eye was carried out by instilling diluted 5% povidone-iodine and 0.5% propaparacaine hydrochloride prior to the start of surgery and after blepharostat placement. Subsequently, a 30G needle set on a 0.3<span class="elsevierStyleHsp" style=""></span>mm syringe is inserted through the peripheral cornea to delicately puncture the central or paracentral area of the anterior lens capsule, allowing the liquefied lens content to be released into the AC without the need for aspiration, in order to, in our opinion and experience, avoid excessive intraocular pressure reduction that could cause a pressure imbalance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The needle is held in the AC for several seconds while observing the liquefied content of the cataract passing from the pre-nuclear intrasac compartment to the AC so that, in this way, the ICP and the AC pressure (ACP) are balanced. At this point it is important to exert a gentle and light pressure with the same 30<span class="elsevierStyleHsp" style=""></span>G needle on the lens nucleus to facilitate the retrolenticular liquefied content to flow through the equator of the cataract forward and into the AC. After a few seconds, the 30G needle is removed from the AC and cataract surgery is continued as in any standard procedure, i.e., performing service paracentesis; in this case the anterior capsule is stained with trypan blue and the AC is filled with with high density OVD, subsequently opening the main incision, performing CCC and finishing with cataract phacoemulsification and intraocular lens implantation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">This technique has been used successfully and without any associated complications in 174 cases of intumescent white and hypermature cataracts with no history of pars plana vitrectomy since August 2018.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">It is known that white, intumescent and hypermature cataracts have a high ICP.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5–7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">If CCC is initiated in the habitual manner and due to the possible sudden loss of pressure difference between the ICP, the ACP and the vitreous chamber pressure (VCP), there is a risk of a radial tear towards the periphery of the anterior capsule, with the possible complications of extension of the tear to the posterior capsule, loss of vitreous and fall of the nucleus into the vitreous,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> especially in an eye with previously open incisions at the beginning of CCC<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,8</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Different techniques have been described in attempts resolve this pressure difference problem. The Brazilian technique described by Figueiredo is based on the fact that, after making 2<span class="elsevierStyleHsp" style=""></span>paracentesis of 0.8<span class="elsevierStyleHsp" style=""></span>mm, and using trypan blue for capsular staining, OVD is injected to pressurize the AC, thus increasing the ACP. Then, the main incision is opened, a “mini-CCC” of 3<span class="elsevierStyleHsp" style=""></span>mm diameter is created and the liquefied intrasac content is aspirated by means of a bimanual irrigation-suction technique together with a rotation of the lens nucleus to allow the exit of the retrolenticular liquefied cortical liquid. Once this phase is finished, the CCC is extended with Vannas scissors, continuing the surgery with standard procedure.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Chee and Chan described the technique they called “capsule milking”. They begin in a similar way to the technique described by Figueiredo with the application of OVD in the capsular center to increase the ACP. Then, the anterior capsule is punctured with a 27G needle on a 3<span class="elsevierStyleHsp" style=""></span>ml syringe to aspirate the liquefied cortex; once the aspiration is done, they “milk” the anterior capsule by applying OVD from the periphery to the center to attract the liquefied cortex from the middle periphery, flattening it and achieving an increase in ACP. Once achieved, standard CCC is performed, followed by the equally standard surgical procedure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The technique of Chan et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> is similar to the one described herein. However, this technique differs from white-puncture in that said authors perform a pre-incision of 80% thickness with a knife and then with a cystome, created with a 27<span class="elsevierStyleHsp" style=""></span>G or 30<span class="elsevierStyleHsp" style=""></span>G bent needle, attached to a syringe with BSS they enter the AC and, prior to the puncture of the anterior capsule and with the aim of increasing the ACP, they inject an amount of BSS until a “sinking” of the lens is observed, at which time CCC is initiated.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the view of the authors, these previously described maneuvers could over-pressurize AC and therefore not allow the spontaneous pressure balance between ACPC, ICP and VCP, which is suggested to occur with the present technique.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Some capsular puncture techniques with Nd:YAG laser or with FLACS<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9</span></a> follow the same concept proposed herein in relation to the need of pressure balance between ICP, ACP and VCP before initiating CCC. Although the authors believe that said techniques have shown good results, we must not forget that they are not available in all hospitals on a routine basis. Moreover, in a recent study comprising 58 eyes with white cataracts that underwent FLACS, Chee et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> observed that in 17.2% the anterior capsulotomy was incomplete and that this was significantly associated with morganian type cataracts and increased lens thickness.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All these described techniques<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5–9</span></a> reduce the risk of the Argentine flag sign in the vast majority of cases; however, there is still a percentage in which it inevitably occurs. In the authors’s experience, no complications were observed during the creation of the CCC with the described technique.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The authors believe that the proposed technique could be effective in reducing the risk of anterior capsular tear, which can occur during intumescent white cataract surgery. The concept of this technique is based on performing it as the first step of the surgery, while the eye is truly watertight, i.e., with an airtight AC. This circumstance allows the ICP to gradually equal the ACP, avoiding in this way the “explosive” radial tear that takes place in certain occasions, when in an intumescent white cataract the ICP is so large that the opening of the previous capsule in a non-airtight or excessively pressurized AC, in addition with the help of the VCP, originates a pressure imbalance that produces a radial capsular tear that equatorially crosses the lens, immediately after the puncture of the anterior capsule.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">In their experience comprising 174 cases, the authors have had no CCC-related complications with the use of this technique. Although it cannot be assured that this is the definitive technique, since studies with a greater number of cases and carried out by different specialists and compared to other techniques are necessary, the authors consider that white-puncture is a simple, fast, reproducible, effective and low cost technique for the management of CCC in intumescent white cataractswhich could help avoid capsular tear and its possible undesirable complications.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">No funding was used for the development of this paper.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">No conflict of interest was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1456425" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1327707" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1456426" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1327708" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Surgical technique" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-11" "fechaAceptado" => "2020-07-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1327707" "palabras" => array:3 [ 0 => "Intumescent white cataract" 1 => "Argentinian flag sign" 2 => "Capsule tearing" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1327708" "palabras" => array:3 [ 0 => "Catarata blanca intumescente" 1 => "Signo de la bandera argentina" 2 => "Desgarro capsular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In order to avoid radial tearing of the anterior capsule while performing continuous circular capsulorhexis (CCC) in a white intumescent cataract, called the “Argentinian flag sign” when CCC is associated with a previous capsular stain with trypan blue, an initial puncture of the anterior capsule is performed with a 30G needle as the first step of the surgical procedure, that means, prior to any previous aperture of the anterior chamber. This act seems to allow the pressure of the intracrystalline space and the pressure of the anterior chamber to be equalized, as the liquefied content of the intumescent white cataract is released into a presumably hermetic anterior chamber, avoiding the dreaded anterior capsular radial tear. This technique, called “white-puncture”, has been used in 174 cases without any associated complications.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Para evitar el desgarro radial de la cápsula anterior al realizar la capsulorrexis circular continua (CCC) que puede ocurrir durante la cirugía en las cataratas blancas intumescentes, el conocido como signo de la bandera argentina cuando se asocia la CCC a una tinción capsular previa con azul de tripano, se hace una punción inicial de la cápsula anterior con una aguja 30 G, como primer paso del procedimiento quirúrgico, es decir, previo a cualquier apertura de la cámara anterior. Este acto parece permitir que la presión del compartimento intracristaliniano y la presión de la cámara anterior se igualen, al liberarse el contenido licuado de la catarata blanca intumescente en una cámara anterior presumiblemente hermética, evitando el temido desgarro radial capsular anterior. Esta técnica, denominada blancopunción, ha sido utilizada en 174 casos sin ninguna complicación asociada.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Blanco A, Rocha-de-Lossada C, Navarro P, Lerner SF, Perrone L, Soler Ferrández FL. Blancopunción: una técnica simple para prevenir el desgarro de la cápsula anterior durante la capsulorrexis en cataratas blancas intumescentes. Arch Soc Esp Oftalmol. 2021;96:97–101.</p>" ] 1 => array:3 [ "etiqueta" => "g" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Perrone D, Albertazzi R. Argentinian flag sign. Video Journal CatRefractSurg. 2001; V.XVII, Issue1.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 492 "Ancho" => 1305 "Tamanyo" => 89669 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a) White-puncture: note how the anterior capsule of a hypermature cataract is punctured as a first surgical step with the help of a 30<span class="elsevierStyleHsp" style=""></span>G needle. b) Anterior capsule opened after the white-puncture and later dyed with trypan blue prior to starting capsulorhexis.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1028 "Ancho" => 1505 "Tamanyo" => 145719 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a) Relationship between intracrystalline (ICP), anterior chamber (ACP) and vitreous chamber (VCP) pressures that occurs in an eye with intumescent cataract. b) Scenario where white-puncture is used as the technique of choice. Note how after puncturing the anterior chamber (AC) with a 30<span class="elsevierStyleHsp" style=""></span>G needle which due to its small diameter can maintain the AC tight and sealed. ICP is balanced with the ACP and VCP, allowing controlled release of the liquefied intumescent lens content. c) Scenario where a previous paracentesis or incision has been made using a minimum amount of ophthalmic viscoelastic substance (OVD). Note the pressure imbalance due to the sudden loss of pressure caused by unsealed AC, which causes the previous capsular tear (Argentinian flag sign). d) Similar to the previous scenario, but in this case with AC overfilling with OVD in an attempt to increase the ACP to match the ICP. In this scenario, the presence of VCP causes a bilateral compression of the intumescent lens mediated by the increase of ACP and the presence of VCP that can cause a tear as an “explosion” of the anterior capsule. As a graphic example, this situation would be similar to what would happen if we squeeze a balloon full of air with both hands: this bilateral pressure could explode the balloon.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Capsule milking: modification of capsulorhexis technique for intumescent cataract" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.P. Chee" 1 => "N.S. 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