Author Affiliations: Department of Ophthalmology, University of California (Drs Menda, Chen, and Naseri) and Department of Ophthalmology, San Francisco Veterans Affairs Medical Center (Dr Naseri), San Francisco, California.
An optimal clear corneal incision creates a self-sealing intrastomal tunnel. Variability in incision length may pose surgical difficulties for subsequent phacoemulsification. An incision that is too long may lead to challenges including decreased instrument mobility, decreased visibility due to corneal striae, stromal hydration, and a difficult angle of approach to the cataract. These sequelae may lead to surgical complications or abandonment of the original incision. We describe a technique for shortening a long clear corneal incision with the intentional creation of a flap of corneal tissue at the posterior internal wound edge. This technique is a simple and quick modification that may avoid the pitfalls of an incision that is too long.
The clear corneal incision (CCI) is the most commonly performed incision in cataract extraction by phacoemulsification.1 Ideal incisions are stable in wound architecture and have a self-sealing, valvelike intrastromal tunnel design.2 Wound architecture may also be important in preventing hypotony and postoperative endophthalmitis.3 Premature posterior entry or delayed anterior entry into the anterior chamber results in a wound tunnel that is too short or too long, respectively. A short tunnel can lead to loss of anterior chamber stability, iris prolapse, and decreased self-sealing tissue apposition. A long tunnel decreases surgical instrument mobility; excessive manipulation of surgical instruments can lead to corneal striae or edema, which in turn decreases intraoperative visibility. A long incision also limits access to subincisional structures, making capsulorrhexis and cortical removal more difficult. Herein, we present a technique for shortening a long CCI.
The shortening of a long corneal incision can be accomplished by intentionally creating a posterior corneal tongue.4 To do this, viscoelastic is first introduced into the intrastromal tunnel to facilitate entry of a paracentesis blade or a metal keratome into the anterior chamber through the original plane of the incision. The cutting edge of the paracentesis blade or metal keratome is then used to make a downward vertical incision at the lateral wall of the intrastromal tunnel to incise the posterior corneal lip at the junction of the tunnel entry into the anterior chamber. This is repeated on the opposite wall of the intrastromal tunnel with the other cutting edge of the metal keratome, as seen in the Figure. This results in a posterior corneal tongue on an internal hinge, effectively shortening the length of the intrastromal tunnel and allowing for a less steep approach to the anterior chamber, as in the . Because of limited mobility within the confines of the wound architecture, it may be difficult to create a purely vertical incision, necessitating a slightly diagonal component to the cut. Alternatively, vertical scissors can be used to create the incisions of the lateral wound edge. Prior to the end of the procedure, it is important to reposit the posterior corneal tongue to its anatomical position and ensure that it is not everted into the intrastromal tunnel, as this phenomenon has been observed to result in postoperative wound leaks.5
Figure. Shortening of a long incision length (IL). A long IL can be shortened with a downward vertical incision at the lateral wall of the intrastromal tunnel (A), creating a corneal tongue (shaded area) on an internal hinge (B), which effectively shortens the IL (C).
A CCI with a long intrastromal tunnel makes phacoemulsification a more technically challenging procedure. Our technique for shortening a long CCI provides a quick, simple modification to allow for better wound control and anterior chamber accessibility. Potential disadvantages of this technique include overcorrection, resulting in a wound that is too short and focal loss of endothelium at the site of the posterior corneal tongue. Additionally, the surgeon may inadvertently widen the wound in an attempt to make a vertical cut, leading to excessive outflow of irrigating solution. In our experience using this technique in 4 cases, there were no surgical complications; the corneal flap was reposited, creating a self-sealing incision that did not require suturing.
In summary, we describe a technique for shortening a long CCI that may avoid the need to abandon the original incision. This technique may be particularly useful in teaching residents cataract surgery when variability in wound construction is common.
Correspondence: Ayman Naseri, MD, Department of Ophthalmology, San Francisco Veterans Affairs Medical Center, 4150 Clement St, San Francisco, CA 94121 (email@example.com).
Submitted for Publication: May 15, 2012; final revision received June 14, 2012; accepted June 15, 2012.
Conflict of Interest Disclosures: None reported.
Online-Only Material: The video is available .
Additional Contributions: We thank Suling Wang, BS, for her work on the Figure.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Ophthalmology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
Shortening a Long Clear Corneal Incision
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.