Incisional Burn Following Phacoemulsification Managed With Deep Anterior Lamellar Keratoplasty

Phacoemulsification may lead to thermal injury at the main incision if the generated ultrasonic energy is not adequately dissipated. Such thermal damage may compromise the corneal integrity by disrupting stromal adhesion and reducing endothelial cell count, potentially leading to postoperative astigmatism and other complications.

Given the high volume of cataract surgeries performed daily worldwide, it is essential to recognize and manage such patients effectively. Additionally, this case serves as an opportunity to discuss different surgical approaches for managing incisional burns, highlighting the role of deep anterior lamellar keratoplasty (DALK) in restoring corneal integrity and function in cases of severe thermal damage.

The patient was initially managed at a regional hospital and was subsequently referred to a tertiary hospital for specialized evaluation and surgical intervention due to the severity of the ocular injury. The case was handled by a corneal and ocular surface specialist due to the extent of tissue compromise and the need for advanced surgical intervention.

A 74-year-old male patient was referred for evaluation after experiencing a thermal injury at the main incision following cataract surgery with phacoemulsification in his right eye (OD). The patient complained of persistent blurred vision and foreign body sensation. The visual acuity (VA) in the affected eye was 0.1, improving to 0.6 with pinhole correction, while the contralateral eye (OS) had normal vision (1.0). Intraocular pressure (IOP) was 6 mmHg in the OD compared to 17 mmHg in the OS.

Anterior segment evaluation revealed a thermal lesion in the superior temporal quadrant corresponding with the incision, with tissue dehiscence and significant epithelial oedema observed also by optical coherence tomography (OCT). Corneal topography demonstrated localized flattening and irregular astigmatism, against the incision. The endothelial cell count in OD was significantly reduced (974 cells/mm²) compared to OS (2723 cells/mm²).

Given the severity of tissue disruption and the lack of adequate stromal adhesion, a deep anterior lamellar keratoplasty (DALK) with a 5 mm graft was performed. This approach was chosen to preserve the host’s Descemet membrane and endothelium, thereby reducing the risk of immunologic rejection by avoiding endothelial exposure to donor antigens.

At the one-month follow-up, the VA improved from 0.1 to 0.4, improving to 0.6 with pinhole correction. The graft remained stable, and a negative Seidel test confirmed the absence of aqueous leakage.

Thermal burn (“phacoburn”) occurs from localized overheating during phacoemulsification and can severely impact on visual recovery. Main factors: inadequate irrigation, excessive ultrasound, tight incisions, prolonged occlusion, and viscoelastic. Incision size and surgeon experience also influence outcomes. Studies show cohesive or dispersive viscoelastics can delay irrigation/aspiration, raising incision temperature. Therapeutic options include conjunctival flap, tenon plug, pericardium patch, scleral graft or keratoplasty depending on lesion severity. Prevention requires careful optimization of phaco parameters, ensuring sufficient irrigation, minimizing ultrasound, avoiding prolonged occlusion and removing viscoelastic before phaco.