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