In this anonymous video we have a phaco incision that is very poorly made. The placement is too far from the limbus and too close to the central cornea. The architecture is weak with a very thin epithelial roof and then a very short corneal stromal tunnel. The incision makes it difficult to access the sub-incisional capsular bag and it does not seal well at the end of the procedure. Even after placing a suture to close the incision, it induces three diopters of corneal astigmatism. You must learn from this case so that you know what to avoid for your own surgeries.
OCT analysis of the incision confirms what we see clinically: a very thin roof of mostly epithelium with a very short corneal stromal tunnel which is too close to the visual axis.
What should have been done differently?
-start closer to the limbus, perhaps making a shallow initial groove to help anchor placement
-angle the keratome blade at a less steep angle, not towards the corneal apex
-fixating the eye with the chopper is tolerable, but may not provide the stability of other instrumentation that is placed opposite the forward force of the blade. In this case, the chopper fixation acts as a pivot point and the incision is inadvertently enlarged as the blade is withdrawn.
-as the blade enters the tissue and it becomes obvious that the architecture is wrong, STOP, withdraw the blade, and do not enter the eye. Choose a different location and try again as shown in this video.
What have we learned from this video?
-we must understand the three basic rules of corneal incisions before coming to the operating room for surgery
-if the incision starts out poorly, it is good to stop and try again at a different location
-stay away from the visual axis -- it is better to have a limbal incision than a totally avascular incision in the clear cornea
-the damage that is caused by a poor incision will affect the patient's vision forever. While this patient has three diopters of induced astigmatism now, it will likely lessen to the 1 to 1.5 diopter range in the future, but it will never be back to normal / baseline.
-you must make it a point of learning from every case that you do
A smart surgeon learns from his/her own mistakes, but a truly wise surgeon can learn from the mistakes of others as well.
