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. [6]

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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. [5] [6] Other risks factors for cataract development in general include[7]:

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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.

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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.

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 . [1]

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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. [8] 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.

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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. [9] Follow these steps on the adjacent tear as well.

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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 Argentinian flag sign is an observation that can occur during cataract surgery for intumescent pearly white mature cataracts. Literature has reported an incidence ranging from 3.85% to 28.3%. [1][2] [3] [4] This finding is named after the Argentinian flag due its resemblance of blue and white stripes. During capsulotomy a radial anterior capsular tear occurs through a trypan blue stained anterior lens capsule. After the tear has propagated equatorially what is left is a light blue torn anterior capsule with a central white cataract now visible through the capsule.

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.

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The differential diagnosis for Argentinian flag sign includes the radial tears of the anterior capsule from iatrogenic manipulation

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