key: cord-0014884-9d066hwm
authors: Mansour, Hana A; Mansour, Ahmad M
title: Autologous tenon plug and patch in phacoburn
date: 2021-01-20
journal: BMJ Case Rep
DOI: 10.1136/bcr-2020-238970
sha: 2789b44e01ee97bc696e75e6f6fc231dc1f45245
doc_id: 14884
cord_uid: 9d066hwm

This 75-year-old woman had phacomorphic angle closure, dense nuclear sclerosis, deep set eye, miotic pupil and tight corneal wound during phacoemulsification. Phacoemulsification wound burn was noted at the end of surgery. Tenon was harvested from the inferior conjunctiva, placed over the gape and anchored by two radial corneoscleral 10–0 nylon. Ten days later, anterior optical coherence tomography showed good wound apposition and sutures were removed with visual recovery to 20/25 (6/7.5) without astigmatism.

Corneal burn during phacoemulsification results from inadequate fluid flow and tight wound. This is a cataract surgeon nightmare because of wound gape. Most surgeons perform primary suturing of the wound resulting in extreme astigmatism and much delayed visual rehabilitation. Other modalities add expenses such as donor cornea and are not available on the spot in most centres. We present a simple inexpensive readily available surgical solution with fast postoperative recovery of vision.

This 75-year-old Caucasian woman had phacomorphic angle closure and moderate severe nuclear sclerosis with best spectacle corrected visual acuity of 6/30 (20/100) in the left eye. Besides a shallow anterior chamber, the patient had very deep-set eye, small palpebral fissure and miotic pupil (maximal dilation to 3.5 mm from intake of alpha 1 blocker). Because of shallow anterior chamber, it was not possible to use pupillary tools (iris hooks would hit the lid margin while pupillary dilation devices would damage the corneal endothelium). Under topical anaesthesia, a limbal 2 mm long and 2.6 mm wide corneal tunnel was done with a crescent knife. Hyaluronic acid 2.5% (Microvisc phaco, Bohus BioTech AB, Strömstad, Sweden) was injected to deepen the shallow anterior chamber as well stretch the miotic pupil. Circular anterior capsulorrhexis was performed with a cystotome and phacoemulsification was initiated in order to create a space for subsequent hydrodissection of the lens nucleus. With the phacoemulsification probe placed over the middle nucleus surface and after allowing aspiration around that area, 1 s of phacoemulsification sculpt mode at low settings was done and was immediately stopped after the appearance of lens milk. After aspiration of viscoelastic material, phacoemulsification was slow using low settings to avoid pupillary touch. Following insertion of the intraocular lens implant, there was a gaping limbal wound with leakage of aqueous.

Subconjunctival lidocaine was injected at 6 o'clock and after one conjunctival snip 1 cm from the limbus, 3 mm of Tenon was harvested and placed over the gape and anchored by two radial corneoscleral 10-0 nylon. A 14 mm soft contact lens (Oasys, Acuvue, Johnson and Johnson, New Brunswick, New Jersey, USA) was placed with great difficulty due to the small space (short palpebral fissure).

Eight hours later, objective refraction revealed 5 diopters of astigmatism and 6/30 (20/100) uncorrected vision. Anterior optical coherence tomography (OCT) revealed good apposition of the graft (figure 1). Forty-eight hour postoperatively, uncorrected vision was 6/9 (20/30). Ten days later, one of the two nylon sutures was removed along with the contact lens. Anterior OCT scan along the removed suture plane complete apposition of the graft (figure 1), and hence the second suture was also removed. Since uncorrected visual acuity stabilised at the 6/7.5 (20/25) level till the 6-month follow-up.

Common approaches for thermal phacoemulsification injuries 1-10 have included tight suturing of the corneoscleral, 4 a fornix-based conjunctival flap, 1 amniotic membrane transplantation, scleral patch graft, lamellar corneal graft 2 or contact lens application. Special suturing techniques are needed to appose the anterior lips to the posterior lips of the wound such as the use of temporary 8-0 nylon traction sutures followed by multiple 10-0 nylon sutures. This latter technique seems to be the most common approach and the sutures are gradually cut over a period of 1 month. With this approach, Sugar and Schertzer 4 encountered very high astigmatism reaching 15 diopters. Even astigmatism not attributable to the tight sutures, but instead to tissue shrinkage, tends to wane with time needing more than 6 months to dissipate (Mattress sutures in phacoburn, Ahmad M Mansour, unpublished data). Other approaches require the presence of donor tissue adding expenses and time lost in the operating room. Haldar and Saraff 1 used a fornixbased conjunctival flap to adequately cover the wound, followed by a single horizontal mattress suture with 10-0 monofilament nylon to appose the wound. This technique appears fit for small to moderate gape. A rectangular fornix based conjunctival flap would not plug a large gape perfectly with one suture like with a Tenon patch, and there is the possibility of a filtering bleb formation with the conjunctival flap. By anterior OCT, internal architecture of the wound is well noted and shows a good seal of the gape by the Tenon 'plug' (figure 2). Also, under OCT guidance, the two sutures were removed one at a time with resolution of the astigmatism.

The known risk factors 3-10 for a phacoburn include shallow anterior chamber, tight wound with wound compression of the irrigating sleeve, sleeve kinking by handpiece movements (with deep set eye), kinked tubing, low irrigation setting, use of thicker viscoelastic material, dense nuclear sclerosis and high ultrasound power. In our case, the eye was small with deep set orbit and we used 2.5% hyaluronic acid to deepen a shallow anterior chamber as well as widen a miotic pupil. In our case not only the initial emulsification was the trigger, the continuous use of ultrasound in this dense cataract in a tight wound added insult to injury and we were a little surprised to find a wound gape at the end of the case. The appearance of lens milk is a warning sign to immediately stop use of ultrasound power. Checking the tubing for clogging by nucleus piece, increase irrigating and aspiration flow, widening the corneal incision, decreasing the ultrasound power and continuous rinsing of the corneal wound by BSS can lessen the chance for a phacoburn.

Treatment of phacoburn with a tenon plug 11 allows good sealing with minimal astigmatism and with quick removal of the nylon sutures. Tenon's capsule is easily available and is composed of fibroblasts that accelerate wound healing yielding a robust scar without extra cost and is not limited by the availability of graft tissue.

► Phacoburns occur in the setting of shallow anterior chamber, tight cataract wound, kinked tubing, low irrigation, thicker viscoelastic material, dense nuclear sclerosis and high ultrasound power. ► Treatment of phacoburn with a tenon plug allows good sealing with minimal astigmatism and with quick removal of the nylon sutures. ► Tenon's capsule is easily available and is composed of fibroblasts that accelerate wound healing yielding a robust scar without extra cost.

Contributors Conception and design, acquisition of data or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content: HAM, AMM. Final approval of the version published; agreement to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated and resolved: HAM, AMM.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Anterior OCT scan through the phacoemulsification incision.

(A) Ten hours after surgery, the wound gape is well sealed by the Tenon graft and 2 radial 10-0 nylon sutures. (B) Ten days postoperatively, one suture is removed and the scan through the removed suture shows no wound gape. Then the second suture is removed and repeat OCT scan through the second removed suture showed a similar finding. Arrows delineate the extent of the Tenon graft. Arrowheads point to the perfect plugging of the wound gape by the Tenon graft. 

Closure technique for leaking wound resulting from thermal injury during phacoemulsification

Corneal surgery for severe phacoemulsification burns

Corneoscleral burn during phacoemulsification surgery

Clinical course of phacoemulsification wound burns

Phacoemulsification conditions resulting in thermal wound injury

Phacoemulsification and thermal wound injury

Case report of a severe corneoscleral burn caused by the phacoemulsification probe

Ultrasound-induced corneal incision contracture survey in the United States and Canada

Phaco transducers: basic principles and corneal thermal injury

Thermal effect on corneal incisions with different phacoemulsification ultrasonic tips

Tenons patch graft in the management of large corneal perforations

Competing interests None declared.

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