Flutter Sign – An Indicator of Intact Anterior Hyaloid Face After Posterior Capsule Rupture During Phacoemulsification

Rohit Om Parkash,1 Tushya Om Parkash,1 Trupti Sharma,2 Rasik Behari Vajpayee,3 Deepak Megur,4 Sourabh D Patwardhan,5 Abhijeet Desai,6 Marie-José Tassignon7 1Department of Cataract Surgery, Dr Om Parkash Eye Institute, Amritsar, Punjab, India; 2Department of Cataract Surgery, Dr Om Parkash Eye Institute, Pathankot, Punjab, India; 3Vision Eye Institute Melbourne; Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, VIC, Australia; 4Megur Eye Centre, Bidar, Karnataka, India; 5Nandadeep Eye Hospital, Sangli, Maharashtra, India; 6Sohum Eye Care Centre, a Unit of Dr Agarwals Eye Hospital, Mumbai, MH, India; 7Department of Ophthalmology, University of Antwerp, VAN, Belgium; Department of Ophthalmology, University Hospital VUB Brussels, Brussels, BelgiumCorrespondence: Tushya Om Parkash, Email [email protected]: To describe the intraoperative Flutter Sign as a real-time indicator of anterior hyaloid face (AHF) integrity following posterior capsule tear (PCT) during phacoemulsification.Design: Single-centre observational study combining retrospective review of twelve intraoperative PCT cases with prospective evaluation of eight additional cases. Retrospective observations guided structured assessment in the prospective arm, focusing on PCT edge behaviour and AHF integrity.Methods: Surgical videos of twelve eyes with intraoperative PCT were analysed for tear edge morphology and motility. Based on these findings, eight prospectively observed PCT cases were examined intraoperatively for edge behaviour and AHF status. Additional parameters included need for vitreous surgery, type of intraocular lens (IOL) implanted, and intraoperative and postoperative complications associated with PCT.Results: Eleven eyes demonstrated sharp, fluttering PCT edges with intact AHF, no vitreous prolapse, and no need for anterior vitrectomy. Of these, five received in-the-bag IOLs, while six underwent sulcus fixation. All achieved a best corrected visual acuity (BCVA) of 20/20. Nine eyes exhibited scalloped, non-fluttering edges, consistent with AHF rupture and vitreous prolapse. All required anterior vitrectomy and sulcus-fixated IOLs. Three patients in this group experienced posterior migration of lens material: two had small cortical or nuclear fragments that were clinically insignificant and required no intervention, while one patient had a large nuclear fragment that necessitated a secondary procedure for removal. BCVA was reduced in two eyes to 20/30. Two patients experienced transient elevation of intraocular pressure. No cases of retinal detachment or endophthalmitis were observed.Conclusion: The Flutter Sign is a simple, dye-free, real-time indicator of AHF integrity after PCT, with fluttering edges signifying intact AHF and scalloped static edges indicating vitreous prolapse.Keywords: anterior hyaloid face, posterior capsule tear, vitreous body, phacoemulsification, cataract extraction, intraoperative complications, Flutter Sign