Argentinian Flag Sign
The Argentinian flag sign. This is an observation during cataract surgery described by Daniel Mario Perrone, MD, through an instructional video presented to the 2000 American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgeons. He described the findings and secondary complications and further outlines preventive steps . 
The Argentinian flag sign is an observation seen most commonly in patients with intumescent pearly white mature cataracts during surgery. Literature has reported an incidence rangeing from 3.85% to 28.3%.    This finding is named after the Argentinian flag due to a distinct phenomenon blending of light blue and white coloration. During capsulotomy a radial anterior capsular tear occurs through a trypan blue stained anterior lens capsules. After the tear has propagated equatorially what is left is a light blue torn anterior capsule with a central white cataract protruding from the capsule.
The Argentinian flag sign typically arises after an initial puncture of the anterior capsule with a self-propagating tear. It has also been observed later in cataract surgery during the process of continuous curvilinear capsulorhexis. It is believed to be the sequela of a pressurized lenticular system compartment subject to posterior to anterior pressure leading to anterior lens nucleus displacement. This movement causes an anterior capsule tear that begins to radialize rapidly to the periphery of the capsule in an undesired and uncontrolled fashion. The Argentinian flag sign is not typically seen in hypermature morgagnian cataracts as these present with a completely liquefied cortex and a free-floating nucleus within the capsule allowing pressured to distribute evenly.
Conditions and predisposing factors to the Argentinian flag sign have yet to be fully defined; however, due to the prevalence of senile pearly white cataracts in areas with poor access to Ophthalmologic care this condition is more common in the third world and developing country settings. Some authors have postulated that trypan blue staining of the anterior lens capsule is a potential risk factor for the development of the Argentinian flag sign; especially in the setting of diabetes as both can lead to a more stiff and brittle capsule.   Other risks factors for cataract development in general include:
- Diabetes or elevated blood sugar
- Steroid use (oral, IV, or inhaled)
- Ultraviolet exposure
- Ocular diseases: Retinitis Pigmentosa, Uveitis
- Ocular Trauma
- Prior ocular surgery
- Procedures: Vitrectomy, Intravitreal injections
- Genetic predisposition
The Argentinian flag sign is seen most commonly in intumescent pearly white cataracts with slight hyper-hydration of the lens fibers. These hydrated lens fibers create anterior and posterior pressures within the capsule separated by an equatorial cortex that has yet to liquefy and thus is still in contact with the capsule. During capsulotomy when the anterior intralenticular pressure dissipates into the anterior chamber, a difference in pressure caused by the remaining posterior intralenticular pressure causes the lens to be displaced anteriorly placing strain on the capsule. A combination of different mechanisms such as insufficient chamber maintenance with viscoelastic or excess posterior pressure such as exhibited during patient exertion during valsalva likely contribute.  As stated previously, the Argentinian flag sign is not typically seen in hypermature morgagnian cataracts as these present with a completely liquefied cortex and a free-floating nucleus allowing pressured to distribute evenly within the capsule.
The clinical diagnosis of Argentinian flag sign is made while in surgery, as it is a surgical complication. It typically arises after an initial puncture of the anterior capsule. It has also been observed later in cataract surgery during the process of continuous curvilinear capsulorrhexis.
Patients with intumescent pearly white cataract on slit lamp exam are predisposition to the development of Argentinian flag sign. It has also been postulated that patients with diabetes have a higher risk of developing the Argentinian flag sign as well. 
The clinical diagnosis of Argentinian flag sign is made while in surgery. It is diagnosed after a bilateral radial tear occurs through trypan blue stained anterior lens capsules while performing capsulotomy or capsulorrhexis. After the tear has propagated equatorially what is left is a light blue torn anterior capsule superiorly and inferiorly with a central white cataract protruding from the bag.
The differential diagnosis for Argentinian flag sign includes the radial tears of the anterior capsule from iatrogenic manipulation
The best management of the Argentinian flag sign is identifying the surgical patient most likely to produce this complication and taking steps to ensure the complication does not occur in surgery. If an Argentinian flag sign is observed it is important to prevent the tear from propagating around the periphery causing a posterior capsular rupture or vitreous loss. The surgeon must promptly recognize the complication and efficiently take steps to correct it. Correcting the complication begins with re-administration of viscoelastic into the anterior chamber followed by attempts to redirect the tear back to its proper trajectory. While applying traction in the horizontal plane, pull the flap circumferentially backward. Follow this step by then directing the capsulorrhexis more centrally.  Follow these steps on the adjacent tear as well.
- Posterior capsule rupture
- Zonular rupture
- Vitreous loss
- Retained nucleus
- Dropped nucleus
- Inability to implant the Intraocular lens (IOL) due to loss of the capsule
- Corneal endothelial damage from extended surgery time
Follow-up is similar for routine post-surgical cataract cases, though likely extra attention will be needed to assess capsule/IOL/zonular stability if a continuous curvilinear capsulotomy is not achieved during rescue.
Prognosis in Argentinian flag sign has not been reported in the literature.
- Preoperative mannitol: Several clinicians will utilize 250 ml of IV mannitol 60 minutes prior to onset of surgery. This technique is employed to maintain appropriate anterior chamber pressures during surgery. 
- Highly cohesive viscoelastic: Dr. Perrone in his original video states maintaining a deep anterior chamber with appropriate pressures is very important while performing capsulorrhexis, thus the use of a highly cohesive viscoelastic agent like Healon GV® or Healon5® (Abbott Medical Optics, Abbott Park, Illinois, USA). The pressure in anterior chamber should always be maintained with the help of visco-elastic and during capsulo-rhexis at no point the anterior chamber should become shallow.
- Phaco capsulotomy: In this technique, which is believed to have originated in India. It too utilizes highly cohesive viscoelastic. After the tri-planar wound is made at the limbus the phacoemulsification tip should enter the anterior chamber without irrigation due to the presence of viscoelastic maintaining appropriate pressures. Direct the tip in a downward angle with the bevel tip facing up directly over the anterior capsule center. Place the phacoemulsification setting to sculpting and advance the tip into the capsule sculpting the cortex. Continue to sculpt to the nucleus. This technique allows for intralenticular pressures to equilibrate, and liquefied cortical material to be aspirated prior to the creation of the capsulorrhexis.  Reapply viscoelastic into the anterior chamber and continue with capsulorrhexis as one typically would.
- Two stage continuous curvilinear capsulorrhexis: Multiple observational and randomized clinical trials have shown two-stage continuous curvilinear capsulorrhexis (CCC) to be superior to a traditional one stage CCC in intumescent pearly white cataract patients.   In one randomized study  patients were assigned to one stage CCC and 13 patients were assigned to 2 stage CCC. In the one-stage CCC technique, the operating surgeon noted high intracapsular pressure in 61.5% of cases with anterior capsule tears occurring in 23% of cases. Additionally, discontinuity of capsulorrhexis occurred in 30.8% of cases. In the two-stage technique, where the first rhexis was roughly 3 mm the surgeon noted high intracapsular pressure in 36.36% of cases and no anterior capsule tears or discontinuity of capsulorrhexis occurred.  A snail-track capsulorrhexis where the initial capsulorrhexis is kept small initially and subsequently enlarged circumferentially has also been employed successfully.
- Depressurizing the posterior intralenticular compartment."This part of the procedure is typically done after the mini capsulorrhexis has been completed. This step is done by bimanual irrigation and delicate shove, twist, and wobble manipulations of the nucleus with the cannula to decompress any potential pressurized compartment prior to achieving a complete capsulorrhexis. One can also make an initial curved small linear puncture with the help of a cystitome and than through that can allow to decompress the lenticular pressure. Also the liquified cortex can be aspirated with the help of canula. Hydrodissection is not to be completed in intumescent pearly white cataract when there is a potential for the Argentinian flag sign as this places more pressure on the posterior intralenticular compartment. Reverse Trendelenberg positioning as well as the use of retrobulbar block with digital massage or Honan balloon cuff are also effective ways to decrease posterior pressure.
- Flap Motility sign: According to Om Parkash R et al,  even in the presence of peripheral extension of anterior capsular tear, an everted and fluttering flap of the tear indicate pre-equatorial tear, while inverted and non-fluttering flap indicate posterior capsule rupture and tear extension beyond the equator. Though this sign may give a safety assurance to the stressed surgeon, it needs further investigation.
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