This is a case of a very mature white cataract in the second eye of a patient who had an Argentinian Flag Sign in her first eye. Knowing there was a high likelihood of this complication occurring in the second eye added a complexity to this procedure and influenced our surgical decision-making.

First, we anesthetized the eye with lidocaine and used Vision Blue (DORC) to stain the anterior capsule. We infused Viscoat (Alcon) and Healon GV (Abbott), a dense high-molecular-weight viscoelastic, into the anterior chamber to tamponade the cataract complex. We used a bent needle cystotome attached to Healon. Once we opened the capsule, we saw a plume of cortical material fill the anterior chamber.

We then took a 27-gauge cannula attached to a syringe of balanced salt solution and aspirated the cortical material from inside the capsular bag to try to decompress this tense white cataract. Once we went back in with Healon GV, we found the Argentinian Flag Sign, despite all efforts to avoid this complication.

We converted to a beer can capsulotomy and then did our usual four-quadrant divide and conquer to remove the cataract safely from within the capsular bag.

Fortunately, the Argentinian Flag Sign, the anterior capsular opening, did not extend beyond the zonules, and we were able to safely remove the entire cataract without any loss of vitreous. The posterior capsule remained intact throughout the procedure. Therefore, we elected to implant our usual monofocal LI61AO lens (Bausch + Lomb) in the capsular bag.

At the conclusion, we had a perfectly centered lens implant in the capsular bag. We used our standard 0.2 mL of triamcinolone, moxifloxacin, and vancomycin, and the patient did great.