Corneal Wound Dehiscence Remote From Radial Keratotomy Scars During Phacoemulsification: Evidence Of Global Biomechanical Compromise In A Bilateral Case

To report a case of intraoperative corneal wound dehiscence at the clear corneal incision site—remote from

radial keratotomy (RK) scars—during IOL cartridge insertion in phacoemulsification, 23 years after 8-

incision bilateral RK. Bilateral comparison with an uneventful fellow eye operated by the same surgeon

using identical technique highlights that RK globally compromises corneal biomechanical integrity beyond

the scar sites themselves, with implications for surgical planning and risk counseling.

Tertiary care university hospital, Department of Ophthalmology, Recep Tayyip Erdogan University, Rize,Turkey.

A 67-year-old male with bilateral age-related cataract presented for surgery. He had undergone bilateral 8-

incision radial keratotomy (RK) 23 years previously. Preoperative slit-lamp examination revealed well-

healed RK scars in both eyes. IOL power was calculated using the Barrett True-K formula to account for

post-RK corneal changes. Sequential bilateral phacoemulsification was planned.

The right eye was operated first. Standard phacoemulsification with a 2.8 mm temporal clear corneal

incision, positioned away from the RK scars, was performed uneventfully. IOL was inserted via cartridge

injector system without complication and postoperative course was unremarkable.

The left eye subsequently underwent the identical surgical procedure by the same surgeon using the same

2.8 mm clear corneal incision technique, again deliberately placed away from the RK scars.

Phacoemulsification was completed without difficulty. However, during IOL cartridge insertion, the

mechanical stress of advancing the injector through the main wound caused sudden corneal wound

dehiscence at the incision site. Critically, the dehiscence originated from the clear corneal wound itself—not

from an adjacent RK scar—suggesting that the 8-incision RK had globally compromised corneal

biomechanical integrity rather than creating only focal areas of weakness. The wound gape resulted in

anterior chamber shallowing and loss of a controlled surgical environment. The IOL was successfully

implanted and three interrupted 10-0 nylon sutures were placed to restore wound integrity. The anterior

chamber was reformed and confirmed watertight.

Postoperative recovery of the left eye was prolonged compared to the right due to suture-induced

astigmatism. Selective suture removal was performed to optimize the refractive outcome, ultimately

achieving satisfactory visual acuity.

Despite identical surgical technique,2.8 mm incision placed away from RK scars,and the same surgeon,only

one eye experienced wound dehiscence during IOL cartridge insertion-underscoring the unpredictable

nature of post-RK corneal vulnerability even 23 years postoperatively.Key lessons:RK weakens the

entire corneal structure;positioning incisions away from scars does not eliminate dehiscence risk;8-

incision RK creates greater biomechanical compromise than 4-incision patterns;surgeons should

consider smaller incisions,manual IOL insertion,or wound-assist devices to minimize mechanical stress;10-0 nylon sutures should be immediately available;patients must be counseled regarding

prolonged visual recovery due to potential suture-induced astigmatism.