Corneal wound dehiscence at a radial keratotomy scar during iol implantation: a bilateral teaching case

To report bilateral sequential phacoemulsification in a patient with high-myopia post-radial keratotomy (RK) corneas and bilateral chorioretinal atrophy, complicated by corneal wound dehiscence at an RK scar during intraocular lens (IOL) implantation in the second eye performed by a supervised resident, and to discuss the structural, refractive, and training-related implications of surgery in this challenging population. A 65-year-old man with bilateral 8-cut RK performed approximately 30 years prior for high myopia (- 16.00 D) presented with bilateral visually significant cataract. Axial length was 28-29 mm in both eyes; post-RK Scheimpflug tomography (Sirius, CSO) showed marked central flattening with simulated keratometry of approximately K1 29 D / K2 35 D bilaterally (mean central corneal power ≈ 31-33 D); preoperative BCVA was 0.05 (20/400) bilaterally due to pre-existing chorioretinal atrophy and posterior staphyloma. Right eye surgery by the senior surgeon (F.S.) was uneventful; a + 16.0 D IOL was implanted and postoperative BCVA reached 0.4-0.5. Left eye surgery was performed by a supervised resident under direct attending supervision. Phacoemulsification of a grade 2-3 nucleus was uneventful; however, during IOL unfolding and implantation, mechanical stress was transmitted along the tract of an old RK incision, precipitating full-thickness corneal wound dehiscence. The attending surgeon intervened immediately, repairing the dehiscence with three interrupted 10 - 0 nylon sutures. Final BCVA in the left eye was 0.3-0.4, limited primarily by pre-existing chorioretinal atrophy rather than by the intraoperative complication.

Post-RK corneas harbour latent structural vulnerabilities that may be unmasked by the mechanical forces of IOL implantation rather than phacoemulsification itself. These cases should be considered high-complexity and assigned exclusively to experienced surgeons. The bilateral design of this case provides a unique intraoperative comparison and highlights the necessity of pre-consent for suturing, realistic visual prognosis counselling, and strict case selection criteria in supervised surgical training programmes.