Eyeworld

42 | EYEWORLD | WINTER 2025 ATARACT C Contact Garg: gargs@hs.uci.edu Hoffman: rshoffman@finemd.com Miller: kmiller@ucla.edu References 1. Holladay JT, et al. Astigma- tism analysis and reporting of surgically induced astigmatism and prediction error. J Cataract Refract Surg. 2022;48:799–812. 2. Langerman DW. Architec- tural design of a self-sealing corneal tunnel, single-hinge incision. J Cataract Refract Surg. 1994;20:84–88. 3. Ernest PH, et al. Relative strength of scleral corneal and clear corneal incisions construct- ed in cadaver eyes. J Cataract Refract Surg.1994;20:626–629. Relevant disclosures Garg: None Hoffman: None Miller: None beyond 2.75 mm, like if there is an unplanned vitrectomy and a lens needs to be placed in the sulcus. The injector can go through 2.75 mm, but he will make the incision closer to 3 mm to make sure he's not placing too much pressure on the eye when trying to insert the injector, so he doesn't promote vitreous prolapse. Dr. Hoffman said that surgeons should be familiar with creation of both clear corneal and scleral incisions, and he added that practice in a wet lab using either pig eyes or human cadav- er eyes is the best means for perfecting these incisions. Dr. Garg said there are many textbooks that have been written on wound construction, noting the book Eye Surgery: An Introduction to Operative Techniques by Georg Eisner has illustrations on incisions and wounds. "It's from 1990, but it's a nice resource when it comes to any wound construction," he said. "We've come a long way with cataract sur- gery, but some of the principal features of cata- ract surgery and fundamentals have remained the same, and one of those is certainly wound construction," Dr. Garg said. "I think under- standing that will make you a better surgeon because knowing the different kinds of wounds you can make, the pros and cons of how they act, when you should use them, and how they close on their own is important. Every step in cataract surgery builds on the previous step. To have a good case, you have to start off with a well-constructed corneal incision." can be made, just posterior to the conjunctival insertion without creating a peritomy. Most incisions are around 2.2–2.75 mm, depending on the blade you're using and the sleeve, Dr. Garg said, adding that certain lenses require a little larger incision. "I tend to have a little larger incision because I like a high infusion sleeve with my phacoemulsification to allow for a very stable chamber," he said. Dr. Garg likes to use a biplanar or triplanar incision. He also noted that around 8–10 years ago, he started adopting a supraincisional pock- et, known as a Wong pocket, above the phaco wound for routine patients. "I take my ker- atome, and about half a millimeter or so in front of the incision, I create a little pocket," he said. "Behind that, I make my phaco incision, then I make a sideport incision. At the end of the case, I use the supraincisional pocket to hydrate the cornea." This, he said, is an easy pocket to hydrate, so you don't have to worry about going into the sides of the incision and getting a lot of leakage as you hydrate the pocket. What you're trying to do as you hydrate a corneal incision is plump it up so that it doesn't leak. "You do that by push- ing, with force, into the stroma of the cornea, injecting fluid, and getting it to balloon a bit," Dr. Garg said. "With a Wong pocket, you hydrate in a similar fashion, but it pushes down on the incision, so it forces the incision closed. In my experience, it's made my hydration step faster and more robust." This technique was devel- oped by Michael Wong, MD. He noted that he will not use this pocket technique for certain patients, for example, in post-LASIK patients where he doesn't want to create a cleft between the LASIK flap and under- lying stroma. He also won't use this option for patients where he knows he's going to put in a suture, like those with RK or post-PKP. "I've also incorporated the Wong pocket into my femtosecond laser template," Dr. Garg said. "When I do my femtosecond laser, I do capsulo- tomy, fragmentation, and astigmatic incisions, then I'll user the laser to create a precise pocket, and I'll use a blade behind or underneath the pocket to make my main incision." Dr. Garg noted that there are some cases where he will choose to enlarge the incision continued from page 41 " Every step in cataract surgery builds on the previous step. To have a good case, you have to start off with a well-constructed corneal incision." —Sumit "Sam" Garg, MD

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