Comment on: Preventing the Argentinian flag sign and anterior capsular tear: A new diagnostic sign can help the surgeon

Dear Editor, The review by LoBue et al.[1] has explained in detail the pathophysiologic mechanisms of intumescent cataracts and the management options practiced worldwide to prevent the Argentinian flag sign (AFS). We would like to add in the investigation that the “double-peak sign” in ultrasonography, as described by Nayak et al.,[2] will provide greater detail about the posterior intralenticular pressure of intumescent cataracts. In ultrasonography, it can be detected well if there is fluid in the posterior compartment of the lens, which indicates elevated posterior compartmental pressure, and there will be a greater chance of anterior capsule tear or runaway after the nick on the anterior capsule. So, while doing ultrasonography for posterior segment evaluation for white or intumescent cataracts, the focus should be on the posterior capsule and posterior compartment of the lens also to find this double-peak sign [Fig. 1]. In comparison to anterior segment optical coherence tomography, it is less expensive and available almost in every eye hospital or clinic in a developing country.Figure 1: (a) Mature senile cataract with some fluid pockets in the anterior cortex (empty red arrow). (b) B-scan ultrasonography with A-scan overlay shows two full spikes compared to the retina and sclera, one corresponding to the posterior capsule of the lens (empty red arrow) and another representing the nucleus posterior margin (empty black arrow). The hypoechoic area between this double peak is due to a liquefied cortexFrom the management options described by LoBue et al., the surgeon should choose the best possible options according to his/her expertise. We would like to add that limited anterior vitrectomy may be another surgical option for these types of cases to prevent AFS.[3,4] Although the procedure is blind, an experienced surgeon can use a 23/25-gauze vitrectomy cutter to decompress the vitreous and decrease the posterior positive vitreous pressure. It helps especially in the situation where there is a bulky nucleus and shallow anterior chamber. So, after vitrectomy, the anterior chamber deepens due to posterior displacement of the lens–iris diaphragm and helps the surgeon to manipulate the instruments better for a comfortable capsulorhexis. Better preoperative preparation for all possible complications with backup intraocular lens options available on the day of surgery will make the operating surgeon far more comfortable. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.