1. Alex Tham, Colin Tan, Christopher Khng
The Invisible Argentinean Flag – Massive Anterior Capsule Split during Viscoelastic Injection
Alex Tham, Colin Tan, Christopher Khng
National Healthcare Group Eye Institute, Singapore
The authors have no financial or proprietary interest in the subject of this topic

2. Introduction Objectives:
To describe an unusual case of sudden, massive anterior capsule split extending to the equator in a soft cataract
To suggest a mechanism to explain this phenomenon.

3. Case Report
An 80-year-old man with nuclear sclerotic 2+ cataract and 20/60 vision was listed for phacoemulsification
The nucleus was noted to be relatively small with a larger cortical component.
During the side-port incision, the anterior capsule was inadvertently engaged (Fig 1)
This caused a 0.3mm linear puncture in the anterior capsule
Figure 1. The tip of the Beaver blade engages the anterior capsule (white arrow) during the side-port incision.

4. Case Report
After viscoelastic injection, a large equator-to-equator anterior capsule split was observed (Fig 2)
There was no vitreous loss.
The surgery was converted to a corneal-section extracapsular cataract extraction, which proceeded uneventfully.
Figure 2. Following viscoelastic injection, there is a massive anterior capsule split (demarcated by white arrows) extending to the equator.

5. Case Report
After viscoelastic injection, a large equator-to-equator anterior capsule split was observed (Fig 2)
There was no vitreous loss.
The surgery was converted to a corneal-section extracapsular cataract extraction, which proceeded uneventfully.
Figure 2. Following viscoelastic injection, there is a massive anterior capsule split (demarcated by white arrows) extending to the equator.

6. Discussion
The safety of phacoemuslfication is dependent on an intact capsulorrhexis [1].
In some cases of white mature cataracts
There is a high endolenticular pressure
This may cause a tear in the anterior capsule to extend to the periphery.
If trypan blue is used to stain the anterior capsule[2]
the result is a central band of white surrounded on either side by bands of blue – the Argentinean flag sign [3].

7. Discussion – Case 1
A similar anterior capsule split occurred in our patient.
The anterior capsule was not stained as the cataract was relatively soft;
Hence the lack of the alternating colored bands, and thus the “invisible Argentinean flag”.
The cataract morphology was not the type commonly associated with a high endolenticular pressure.
The tiny puncture in the anterior capsule did not extend initially.
It extended after the viscoelastic was injected into the anterior chamber, which was slightly overfilled.

8. Discussion
Proposed Mechanism
Anesthetic fluid volume from the peribulbar injection contributed to raised orbital [4,5] and vitreous [6] pressure.
The viscoelastic injection resulted in raised anterior chamber pressure, with consequent compression of the lens between these opposing two forces.
Diagram taken from
Done by Dr Daniel Mario Perrone, MD

9. Discussion Proposed Mechanism
Under such pressure, soft lens matter extruded through the anterior capsular puncture, resulting in a split propagating to the periphery in both directions.
The type of cataract, with a greater soft cortical component, also likely played a major factor in the occurrence of this complication.
A dense brunescent lens with little cortical component would be more resistant to such compression forces.
Diagram taken from
Done by Dr Daniel Mario Perrone, MD

10. Discussion – Case 2
This was found true in a subsequent surgery on a dense, brunescent cataract in a 63-year-old man.
Inadvertent puncture of the anterior capsule resulted in a 0.5 mm defect
This remained stable even when the anterior chamber was filled completely with viscoelastic.
Conclusion:
This case illustrates the potential for a large anterior capsule split in softer lenses during viscoelastic injection.
Surgeons should exercise great caution when proceeding with phacoemulsification
They may wish to convert to extracapsular cataract extraction.

11. References
Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg 1990; 16(1):31-37. 
Melles GR, de Waard PW, Pameyer JH, Hoadijn Beekhuis W. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999; 25:7-9. 
Perrone D, Albertazzi R. The Argentinean flag sign. Video Journal of Cataract and Refractive Surgery. 2001; Vol. 17:Issue 1. 
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