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Cataract

Suresh K. Pandey

Suresh K. Pandey1-2 MS, ASF (USA), Vidushi Sharma1 MD, FRCS (UK)
1. SuVi Eye Institute & Lasik Laser Centre, C 13, Talwandi, KOTA, Rajasthan, INDIA 2. Visiting Assistant Professor, John A Moran Eye Center, University of Utah, Salt Lake City, Utah, USA

he rst step in cataract surgery is to ensure that both the patient and surgeon are comfortably positioned. Phacoemulsication is routinely performed with the patient lying supine with the head at. Achievement of cataract surgery by phacoemulsication depends on each step of the case being completed successfully. On arrival to the operating room, ideally patients should be positioned supine with their head in correct position allowing adequate visualization of the eye. Despite modern surgical technology and design, some patients will always challenge surgical ingenuity, but with creativity, modications to positioning and ongoing innovation of the cataract surgeons, successful and uncomplicated cataract surgery can be performed. In routine cataract cases, this rst, crucial step of surgeon patient positioning is likely not given much attention. If a patient has a medical condition that precludes them from being able to be positioned properly, then both the patient and

surgeon may be uncomfortable, not resulting in an optimal surgical experience. If there is compromise to the surgical view secondary to ill positioning, then there is potential risk for increased complications. Medical conditions where positioning of the patient is challenging Kyphosis Chronic obstructive pulmonary disease Congestive heart failure Cerebral palsy Myotonic dystrophy Obesity Menieres disease

Figure 1: Patient with severe thoracic kyphosis

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Figure 2: Patient on Operation Table in seated position with the help of few pillows

Techniques of Phacoemulsification in Postural Disorders


Patients unable to recline properly present a challenge for cataract surgeons. A comfortable patient is more likely to cooperate and is more liable to tolerate the procedure in case it takes longer than expected. Successful cataract surgery requires ne precision and good surgical technique of the surgeon. In order to accomplish this, the patient and microscope need to be positioned correctly. Typical positioning of a cataract surgery patient is supine with head at or slightly extended to optimize the red reex and surgical view. Various medical conditions prevent a patient from assuming the ideal position and modications need to be made to rectify unsatisfactory positioning. The various techniques which have been reported to solve positioning problems in these patients include-

Standing Phacoemulsification in Reverse Trendelenburg position2


Standing phacoemulsication technique was employed for morbidly obese patients. Their report discussed a standing phacoemulsication technique where the surgeon is standing, the surgical microscope is at minimum magnication and in the maximum upward position, and the patient is positioned in reverse Trendelenburg position. Placing the patient in reverse Trendelenburg position may help reduce posterior venous pressure by reducing central venous pressure. Patients with morbid obesity face a variety of health complications including an increased risk of cataract and elevated intraocular pressure.

Side Saddle Position3


In an alternative to standing while using the operating microscope, a side saddle position of the surgeon has been described. The patient was positioned on the operating room table and the lowest inclination tolerable and the operating microscopes axis was tilted back 60 degrees toward the horizontal. The foot pedals are placed parallel to the long axis of the operating table. The patients head is rotated towards the surgeon and/or in a chin up position. The surgeon sits side saddle with his or her thighs parallel to the long axis of the operating room table and facing the head of the bed. The globe is tilted slightly more superotemporally than usual to optimize visualization of the red reex and an inferotemporal surgical approach is utilized. This scheme suggests an alternate posture for surgeons, but is rather familiar to surgeons that operate from the side. Surgery may be facilitated with topical anesthesia allowing the patient to xate at the surgeons desired requests. The more upright the patient, the more the operating microscope must be adjusted towards the horizontal, and consequently the surgeons arms will be more outstretched. The surgeon must make the

Face to Face Position1


In this technique, the patient is placed in a standard reclining cataract surgical chair in an almost upright, seated position. From there the ceiling mounted surgical microscope is rotated to 60 degrees from vertical, pointing towards the patient. The surgeon positions himself to the right of the table, facing the patient. The surgeon has to operate with outstretched arms at nearly arms length. Topical anesthesia without sedation can be used which is felt to be advantageous allowing the patient to follow requests of where to xate. Furthermore, with the surgeons arms outstretched and at an unfamiliar angle, adaptations to the approach of surgery have to be made. The case report discusses that an inferior surgical approach via clear corneal incision at 270 degrees was used.1 Neither of their two cases had any complications, and no literature could be found to suggest that an inferior approach would lead to greater postoperative complications.
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Figure 3: Surgeon performing phacoemulsication in standing posture

decision as to whether sitting side saddle or standing is more comfortable.

Conclusion
Conditions causing difculty in positioning during cataract surgery include orthopedic problems like kyphosis, spondylitis, neurological and psychological problems, Cardiovascular and Pulmonary problems, severe obesity and Menieres disease. Modications described in literature for patients who cannot lie supine include patient reclining with neck extended achieving near normal position; trendelenburg position if no medical risk; side-saddle position with microscope tilted; face-to-face position with microscope tilted (using inferior corneal incision); and standing position of surgeon. Therefore conditions precluding a at, supine position of patient can be managed by adjustments to the operating chair/table and use of pillows keeping things familiar for surgeon. If not, surgeon has to adopt an unfamiliar position. The surgeon standing is useful approach with microscope etc. in the normal position. It is important to ensure the patient is comfortable before starting. While performing phacoemulsication in standing position, the surgeon cannot use both microscope and phacoemulsication foot pedal simultaneously. Therefore it is essential to adjust microscope position carefully and keep one foot steady. Do not delay such cases too much where they become more difcult.

Phacoemulsification in Standard Waiting Room Chair4


The modications made to a standard waiting room chair with reported success in patients with both respiratory disease and claustrophobia demonstrate ingenuity and inexpensive design. The reported chair was constructed to have an adjustable headrest afxed to the back of the chair, thus allowing the patient to remain seated upright with their head tilted back but supported. Other minor adjustments were made to the chair such as adding weights for stability and lowering the height so that the patients legs can be extended outward to provide counterbalance. These examples could prove useful for a particular patient that can tolerate sitting but with their head extended back. A Case: A 56 year old man presented to us with decrease in vision in both the eyes. The patient had an age related cataract in both eyes. He has severe congenital thoracic kyphosis and therefore unable to lie at on operation theater table (Figure 1). The patient consulted several ophthalmologists however most of them were uncomfortable performing his cataract surgery as he was unable to lie at on table. We took this patient to the operation theater and performed a mock drill to achieve his best positioning there. We adjusted microscope and phacoemulsication machine foot switch to have an idea about performing his surgery. The patient was seated on table with the help of few pillows (Figure 2). The microscope and phacoemulsication machine were positioned. Standard topical phacoemulsication procedure was performed in the right eye with patient in a seated position by a surgeon in standing posture (Figure 3). An AMO Signature phacoemulsication system (Ellips Transverse Ultrasound) was used. AMO Sensar foldable IOL was implanted in the capsular bag. The surgical procedure was uneventful. Post operatively, the patient achieve 6/6 vision unaided. We have presented the video of this surgery at ASCRS Film Festival.5 The details of the surgery can be seen on following link: http://www.youtube.com/watch?v=V0DnK0Q_RKM&list= UU12vTF4P0xWnhvjGbG2h94w&index=3&feature=plcp

References
1

Ang GS, Ong JM, Eke T. Face-to- face seated positioning for phacoemulsication in patients unable to lie at for cataract surgery. Am J Ophthalmol 2006;141:1151-1152. Gordon MI, Rodrguez AA, Olson MD, Miller KM. Pillow case. J Cataract Refract Surg 2005;31:1824-1825. Prasad S, Kamath GG, Phillips RP. Phacoemulsication in a patient with marked cervical kyphosis. J Cataract Refract Surg 2000;26:12581260. Fine IH, Hoffman RS, Binstock S. Phacoemulsication performed in a modied waiting room chair. J Cataract Refract Surg 1996;22:14081410. Pandey SK, Sharma V. Phacoemulsication in Severe kyphosis. Video presented at American Society for Cataract & Refractive Surgery (ASCRS) Film Festival, Chicago, USA, April 2012

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