1.Identify the intraoperative complication 2. what measures can be taken to prevent it. 3. how to proceed further in case we encounter such condition?

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it is Argentinian flag sign of runaway and escape of rexis into periphery and yes prevention better than cure this is a classical case of mature cataract where before surgery tablet diamox 2stat can be given along with liquid oral GLYCEROL and or mannitol 100 ml just before surgery and surgery under block with massage and may use pinky ball as another option to message... also when doing rexis

Agreed Dr Ramchandra
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1) Argentina flag sign during surgery on mature intumescent lens. It happens when after we stain the capsule with trypan blue and start capsulorrhexis. The first nick suddenly extends to the edges due to high intra lenticular pressure causing the anterior capsule to be tightly stretched 2)The anterior capsule has to be relaxed both by giving hyperosmotics preoperatively or by reducing the Intra lenticular pressure intraoperatively. I do the latter by aspirating some lens matter with the capsulorrhexis needle immediately after giving the first nick. Once the tension on the anterior capsule is sufficiently lowered, I go ahead with the rhexis. Another option is milking of the lens by making a small nick in the centre and then using a symcoe to gently push some cortex out through the opening. 3)Once i see this sign, I make a small snip on one side of the tear with a vannas scissors and then use a rhexis forceps to make a rhexis on one half of the capsule. Then repeat same in the other half.

nicely explained sir
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yes it is argentinean flag sign in intumescent cataracts and hypermature cataracts best way to prevent is to use healon 5 which will flatten the ant capsule then performing small rehxis which latter cn be enlarged after devulking of nucleus even after giving acetazolamide and mannitol this sign can be seen experts can progress with case by giving cuts with vannas scissors and completing rhexis but still high possibility of pcr so if one does not want to compromise with pts eye, must convert into ecce as these pts hv waited so long for sx they will be much happier if gain vision with glasses

Argentinian flag sign. Can be prevented by administering Acetazolamide pre-op. Intra-op, fluid from within the bag should be aspirated using a cystitome needle attached to a syringe and/or start CCC under Healon/Viscoat. In case this occurs, enter through main incision, user a Vanna's scissors under Viscoat/Healon to make cuts on the capsule, so as to complete the CCC with forceps. During phaco, reduce bottle height & AFR. Proceed very slowly using lots of VED

thank you dr shreyans
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I would like to do phaco in anterior chamber in cover of repeated viscoat or aurocoat with viscomet also but if one is not confident enough or beginners better to convert to sics in such cases and later on converting to a partial rexis from upper and lower half of the torn edges with micro scissors and micro forceps of V-R Surgery it also advisable to have a retina backup as high chances of drop nucleus in continuation to phaco...

Argentinian flag sign of rhexis in dye stained milky white cataract, which lead to further bad outcome of sugery; it is prevented by reducing iop before surgery chose better viscoelastic and careful capsulorhexis; if occur put viscoelastic do capsulorhexis in different manner and not to disturb this tearing end

Argentinian flag sign in hypermature cat.liquified cortex causing rise of iop cause runaway rhexis. remove d liquefied cortex wid a simcoe frm a capsular nick bfre dng a rhexis. aspirate d cortex n once d bag is free of free cortex keep dng d rhexis.

extended ccc usually encountered with such morgagnians use Duo viscoat try initial small puncture decrease bag pressure increase Ac pressure ,low vacc ,flowrate high power iris plain phaco,best convert to manual SICS

I mean before doing rexis fluid can be aspirated from side port with 26 or 24 gauge needle to decrease intralentricular pressure or to do a phaco punch in the centre of lens

I would like to add here that we shouldnt aspirate the lenticular material ie the milky white thing as it can lead to extension of the rhexis. make a nick in the center of the capsule . let the fluid come out. displace it with viscoelastic than aspirating. try doing it and there is never a capsular rhexis extension. We get a nice CCC in the process
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orange peel technique of rexis is also successful in such cases with needle or rexis forceps to start with a small rexis and then enlarge it gradually

absolutely right Dr ramchandra. little difficult for beginners though as there is fear of extending the rhexis
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