Argentine Flag Sign Despite Preoperative Anterior Capsule Puncture In An Intumescent Cataract: A Case Report

To describe the occurrence of the *Argentine flag sign* despite *preoperative anterior capsule puncture* in a case of a *tense intumescent white cataract* and to discuss the implications for surgical technique adjustments to prevent complications.

The surgery was performed at the Dr. Pedro Lagleyze Ophthalmology Hospital, Buenos Aires, Argentina, a tertiary referral center specializing in ophthalmic surgery. The procedure was carried out by a resident in training under supervision, highlighting the challenges of managing intumescent cataracts in a teaching environment.

A 44-year-old male with a tense intumescent white cataract in the left eye underwent phacoemulsification. Preoperatively, a white puncture of the anterior capsule was performed to balance intraocular pressure and prevent a runaway capsulorhexis. Despite this measure, during trypan blue irrigation, the Argentine flag sign was observed due to increased intracapsular pressure. The surgical approach was immediately adjusted to stabilize the capsulorhexis and prevent radial extension.

The Argentine flag sign was identified early, allowing timely modifications in the surgical technique. The procedure was completed without posterior capsule rupture or major complications. The patient achieved unaided visual acuity of 20/25 at one month postoperatively, with a well-centered intraocular lens and no signs of postoperative inflammation.

Even after preoperative anterior capsule puncture, increased intracapsular pressure can still lead to an Argentine flag sign. Surgeons must remain vigilant and be prepared to modify their approach to stabilize the capsulorhexis and ensure a safe phacoemulsification procedure in intumescent cataracts. This case highlights the importance of intraoperative adaptability in residency training.