Managing a sticky situation: Real World Ophthalmology

Corneal wound burn is a potential yet underrated complication in cataract surgery, and recognizing its early signs is crucial for proper management.

To prevent corneal wound burn, optimize phaco ultrasound settings, create precise incisions, and execute careful pivoting within the incision.

When dealing with a burned incision, abandon it, suture it securely, and create a new incision.

Watching educational videos and reviewing recordings of your surgeries can provide valuable insights into areas for improvement and help you refine your surgical skills.

Whether you're a novice or a seasoned ophthalmologist, the more cases you handle over the years, the higher the likelihood of encountering complications and challenges. One such complication, corneal incision contracture (CIC) or corneal wound burn, is often underestimated in cataract surgery. In the inaugural episode of Real World Ophthalmology Podcast, Lisa Nijm, MD, J.D. founder of the Real World Ophthalmology, and Dr. Shanika Esparaz, a cataract surgeon and medical retina specialist, discuss the pearls and pitfalls of managing corneal wound burn with guest of honor Professor Uday Devgan, an award-winning and nationally recognized true expert in the field of ocular surgery and former Chief of Ophthalmology at Olive View UCLA Medical Center.

CIC happens in an instant, and recognizing, dealing with, and reacting to the early signs of the wound burn is of utmost importance. Anticipating potential risks and creating a plan to manage them is the initial and crucial step in preventing corneal wound burn. For novice surgeons, in particular, a dense cataract with a lot of phaco energy, a clogged phaco needle, and failure to pivot the needle correctly are the most common hurdles they face. Failure to pivot can lead to a host of issues that can compromise the success of the procedure, such as a shallow anterior chamber, loss of viscoelastic, wrinkles in the cornea, and an inability to control the creation of the capsulorhexis. These problems can have a significant impact on the outcome of the surgery and increase the risk of complications such as phaco wound burn and corneal irregularities.

“When you see the wound in progress and notice that by white smoke, tip failure flow, or maybe a leaky incision, you need to react! And one thing to react is to take your foot off the gas and stop delivering ultrasound energy!” said Devgan. The best option when dealing with a burned incision is to abandon it, suture it securely, and create a new incision to complete the case. Repair the corneal defect using a radial suture initially, then secure the wound edge with a horizontal mattress to safeguard the cornea's integrity. The key to horizontal mattress suture is that it helps pull the roof of the incision down to the floor across the entire width of the corneal tunnel. Finally, create a new main wound.

Having an unprecedented complication for cataract surgery can be an uncomfortable situation for communicating with and earning the trust of your patients. The key here is time, as corneal wound burns tend to recover well with time. Talk to your patients, leave the sutures in place for a couple of months, and watch the patient with serial topography, as the phaco wound burn can result in a noticeable astigmatic effect during the postoperative period. As a final pearl of wisdom, give your patients the best care they need by staying in communication with them during the post operative period.

While phaco wound burns are uncommon, it is crucial to acknowledge their potential occurrence. To mitigate the risk and achieve optimal visual outcomes for our patients, it is essential to optimize phaco ultrasound settings, create precise incisions, and execute careful pivoting within the incision. Additionally, watching educational videos and reviewing recordings of your own surgeries can provide valuable insights into areas for improvement and help you refine your surgical skills. By taking these steps, you can continually improve your performance and provide the best possible outcomes for your patients.

Check out the full episode on Spotify, Apple podcast, Cast box or on realworldophthalmology.com

Helia Ashourizadeh, M.D. is a post-doctoral research fellow at Mayo Clinic, MN, who completed her medical training at Shahid Beheshti University of Medical Sciences. Tune in to the Real World Ophthalmology Podcast to learn from the experts in the field and enhance your practice. Real World Ophthalmology is a platform made for and by early-career ophthalmologists and trainees to enhance education and practice for young ophthalmologists.