EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/76185
July 2012 Positioning problematic cataract patients for success by Maxine Lipner Senior EyeWorld Contributing Editor Face-to-face approach promising for challenging cases I t's a standard part of cataract surgery—the patient comes in and lies down on the table. But what if the patient can't lie down? Finding himself in this circumstance with a patient with a rigid spine due to ankylosing spondylitis, Tom Eke, M.D., consultant, Norfolk & Norwich University Hospital, Norwich, Eng- land, took a different approach—he simply rotated the microscope to view the eye and seated himself across from the patient as if they were having a conversation. In a 2011 issue of the Journal of Cataract & Refractive Surgery, Dr. Eke and fellow investigators reported on a case series of 36 eyes in which the surgery was performed using the seated approach. Seated technique In this technique, the patient sits upright in a standard surgical chair, using as much recline of the chair back as the patient can tolerate. The head is reclined back as far as pa- tient comfort allows, and the micro- scope is rotated away from the vertical so that the patient can gaze directly into the operating micro- scope light. "It helps a lot if the pa- tient can turn his face or get his chin up to face the microscope. "Sometimes we can take 10 minutes getting the patient and my- self comfortable, so I book a double slot for these cases," Dr. Eke said. Topical intracameral anesthesia allows fine-tuning of eye position and ensures that the globe remains perpendicular to the microscope. "The more upright the patient is seated, the more likely it is that I'll be more comfortable standing than sitting," he said. "I can't imagine myself doing this with any block other than topical intracameral anesthesia." Surgical incision is in the lower half of the cornea, and the bottle is raised to compensate for the elevated head, but otherwise the surgical technique is standard. With the technique, the patient is sitting up with his face reasonably vertical. Some patients are com- pletely upright, but usually Dr. Eke Meniere's disease, those with anky- losing spondylitis, as well as others with severe obesity or neurological, breathing, or muscular problems. He finds that the most common case scenario is a combination of a bent neck and inability to lie flat, often due to arthritis and COPD or cardiac failure. "I've done several patients who had previously been refused surgery by their ophthalmologist or anesthesiologist," he said. "For some of these people, face-to-face posi- tioning is the only realistic alterna- tive to blindness." The patients themselves give the face-to-face technique high marks. Dr. Eke conducted a survey of pa- tient comfort and found that all were grateful. "They all genuinely said that they were comfortable, and comfort scores were very similar to those I get with standard supine po- sitioning. All said that they would be happy to have the same position- ing in the future." Source: Thinkstock/Comstock Images/Getty Images tries to have them recline a bit. "The nearer I can get them to face the horizontal, the easier it is," he said. "If they're completely upright then I have to rotate the microscope by almost 90 degrees, which does make the surgery more difficult." Dr. Eke found that results were promising with the approach. Since submitting the case series he has performed 16 more cases using this position, nearly all with good re- sults. "I've had one capsule rupture out of 52, which did have a dropped nucleus—a worst-case scenario," he said. Luckily the patient was a candi- date for general anesthesia and did reasonably well in the end. So far this outcome appears on par with the typical U.K. posterior rupture rate, which is 1.92%—1 out of 52 cases. At the moment, even with the unusual positioning, Dr. Eke, who has just completed his 52nd case, finds himself with this same rupture rate of 1 out of 52 cases. "I would think that it would have a higher capsule rupture rate than average because I'm in an unfa- miliar position and my arms are sticking forward a bit and sometimes I'm in a slightly uncomfortable posi- tion myself, but actually the num- bers are pretty reasonable," Dr. Eke said. He acknowledged that there's no telling what will happen in future cases, and he does warn all patients of the risk of serious complications. There has also been some con- cern that the position may result in an increased rate of endophthalmi- tis, since the incision is placed on the bottom half of the eye rather than up at the top. Dr. Eke uses a long corneal tunnel and so far, he has not come across an endoph- thalmitis case. Dr. Eke reserves the technique for those who cannot lay flat or who cannot be accommodated by other modified positioning. Some patients who can be accommodated by the technique include those with severe Other extreme positions Kevin M. Miller M.D., Kolokotrones professor of clinical ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, UCLA, sees the technique as a variation of approaches others have taken. "In a sense we're all face-to-face; it's just that we're looking down at their face rather than seated across from them," Dr. Miller said. He is no stranger to performing cataract surgery in unusual posi- tions. In two cases Dr. Miller found that a stack of pillows could provide the answer for patients who could not be positioned normally. The first case, which was published in the September 2005 issue of the Journal of Cataract & Refractive Surgery, in- volved a cataract patient with de- generative joint disease and severe kyphosis. Using 11 pillows beneath his buttocks and legs and three be- neath his head and neck, Dr. Miller was able to effectively perform the surgery. In the second case published online in the February 15, 2010 issue of Ophthalmic Surgery, Lasers and Imaging, Dr. Miller performed a similar surgery on a patient with ankylosing spondylitis and a severe neck deformity. For the surgery, 25- 30 pillows were placed beneath his continued on page 25 EW CATARACT 23