Delayed radial keratotomy dehiscence following uneventful phacoemulsification cataract surgery

Abstract

Sir, Delayed radial keratotomy dehiscence following uneventful phacoemulsification cataract surgery A 73-year-old female was referred with cataracts. Bilateral radial keratotomy (RK) had been performed 9 years previously for high myopia; on her left eye this had been supplemented with astigmatic keratotomies. Best-corrected visual acuities were 6/36 right eye and 6/12 left eye. She had bilateral moderate nuclear sclerotic cataracts. Fundoscopy showed healthy discs with a right epiretinal membrane and normal left macular. She chose to have left cataract surgery following detailed discussion with specific mention of complications associated with previous RK.Routine phacoemulsification cataract extraction was performed under subtenons anaesthesia. The clear corneal main incision was located temporally between RK incisions and was secured at the end of the procedure with a single 10/0 Vicryl suture. She was examined before discharge and had a deep anterior chamber and negative Siedel's test. Acetazolamide 250 mg was given for postoperative IOP prophylaxis.Day one review showed a shallow anterior chamber with two Seidel positive temporal RK incisions. She was taken to theatre and one incision closed with a 10/0 nylon suture and a bandage contact lens inserted (Figure 1). Four months postoperatively her visual acuity is 6/6 with refraction À0.25/À2.00 Â 7.5 CommentPrevious RK not only complicates intraocular lens power selection due to unintentional postoperative hyperopia and postoperative hyperopic shift, 1 but can also reduce corneal tensile strength. RK incision dehiscence has been reported during phacoemulsification cataract surgery 2-4 corneal transplantation 5 and following blunt trauma including car airbag inflation. 6 Previous reports suggest considerable variability in corneal strength following RK. [2][3][4][5][6][7][8] We are aware of three published cases of RK incision rupture during phacoemulsification cataract surgery. Budak et al 2 reported RK incision dehiscence in a patient who had RK 11 months before cataract surgery. This occurred during construction of a 3.0 mm incision that intersected one of the radial incisions. Following suturing of the wound, the remainder of the procedure was uneventful. In the other two cases, RK dehiscence occurred during the phacoemulsification stage. 3,4 In all cases there was very good visual rehabilitation.The reason why delayed RK dehiscence occurred in our patient is not known. The astigmatic keratotomy incisions traversing radial cuts will have further weakened the cornea compared with simple RK. As trauma to the eye is unlikely because the clear shield was only removed at the day one examination, we speculate

Outcomes of femtosecond laser–assisted cataract and refractive lens surgery in patients with prior radial keratotomy

“…Wound dehiscence has been reported during the postoperative course although this is rare. 7 The literature reports increased precision and reproducibility of anterior capsulotomy with laser-assisted cataract surgery over conventional cataract surgery; however, a recent meta-analysis of 3,554 cases found that risks for incomplete capsulotomy, anterior capsulotomy tags, and anterior capsule tears were significantly higher with FLACS in routine cases. [18][19][20][21] The FEMCAT trial (nearly 1500 eyes) found no significant difference in overall clinical outcome between routine phacoemulsification and FSassisted methods, including complication rates in routine eyes, which was further supported by a recent meta-analysis reporting that both methods are safe and effective with no difference in mid-term visual acuity.…”

Effects and risks of 3.2-mm transparent corneal incision phacoemulsification for cataract after radial keratotomy

“…14 reported one case with intraoperative RK incision dehiscence during a 3-mm transparent corneal phacoemulsification procedure 30 years after RK. Day and Seward 11 reported a case with no intraoperative dehiscence of the RK incisions during transparent corneal phacoemulsification 9 years after the RK procedure. However, wound leakage was observed in two RK incisions on the first postoperative day.…”

“…7 The conventional transparent corneal incision performed for phacoemulsification may lead to dehiscence of the RK incision. [8][9][10][11][12] Once RK incision dehiscence has occurred, phacoemulsification can be continued after suturing the dehiscence. 8,10 It has been suggested that when the spacing between two adjacent RK incisions is large enough to exceed the width of the transparent corneal incision, a transparent corneal incision can be considered for cataract surgery; otherwise, a scleral tunnel incision is recommended to avoid intersecting the RK incisions.…”

Outcomes of Phacoemulsification Using Different Size of Clear Corneal Incision in Eyes with Previous Radial Keratotomy

“…In one case, no dehiscence was noted intraoperatively, but two RK incisions were Seidel positive at post-operative day 1. They were treated with sutures and a bandage contact lens [4]. …”

“…Postoperative eye drops or oral medication may be prescribed to reduce intraocular pressure in the immediate post-operative period. Even if the surgery goes well, re-examination is always needed 1 day after the surgery to determine if there is delayed RK incision dehiscence [4]. …”