Creating a clear corneal incision requires a precise approach to ensure the wound is self sealing and stable throughout the procedure. Some surgeons utilize a dimple down technique where they intentionally point the tip of the keratome downward to engage the deeper stromal fibers before leveling out to enter the anterior chamber. However, as this case demonstrates, if the downward angle is too steep or the maneuver is not carefully controlled, the sharp tip of the keratome can easily travel across the shallow peripheral chamber and inadvertently puncture the anterior lens capsule. This creates an immediate and unplanned capsulotomy that can quickly run out to the periphery before the surgery has even truly begun. To avoid this complication, always maintain a parallel orientation to the iris plane once the keratome has entered the stroma and ensure the eye is properly pressurized with viscoelastic if the chamber is shallow. Precision at the incision stage is the foundation of a successful case, so keep that blade flat and away from the delicate lens capsule.
