EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/137624
26 EW CATARACT June 2013 Complicated cataract cases Modifying chair may help in complicated cases by I. Howard Fine, MD E very now and then, patients with back, neck, or breathing problems come in for a consultation, seeking advice regarding management of their cataracts. Often they have been to other ophthalmologists already and have been told that their surgery will be difficult because of problems positioning them beneath an operating microscope. These patients have forced some of us, who have been around the block a time or two, to think outside the box and come up with new engineering solutions. Steve Rimmer, MD, and I published the first of what turned out to be a series of articles describing how patients can be managed creatively. Our patient could not recline at all, not even 5 degrees from the vertical upright position, because she suffered from interstitial lung disease and was severely hypoxic.1 She wore a facemask with 6 L per minute of oxygen and was very tachypneic. To perform surgery on her dense corticosteroid-induced posterior subcapsular cataract, we had to allow her to sit bolt upright on an operating table. We used loupes instead of an operating microscope to visualize her cataract. We braced our hands on the patient's cheek to steady ourselves for the surgery, which we performed through an inferotemporal clear corneal incision. In another case, we used a large number of pillows to position a patient with a severe kyphosis on his back in the Trendelenburg position. His buttocks and legs were much higher than his head, and his head had a 30-degree downward tilt. In this position, on separate days, we were able to complete his surgery successfully on both eyes.2 In yet another case, we used almost twice as many pillows as in the previous case to operate on a patient with a severe neck fracture. His head was at a 90-degree angle to his torso.3 In this issue of EyeWorld, I. Howard Fine, MD, describes his innovative solution using a modified waiting room chair. He describes the advantages of this approach over techniques utilizing modifications to an operating room table. Creative solutions such as these should be considered for the occasional patients who come along with challenging systemic conditions. References 1. Rimmer S, Miller KM. Phacoemulsification in the standing position with loupe magnification and headlamp illumination. J Cataract Refract Surg 1994; 20:353-4. 2. Gordon MI, Rodriguez AA, Olson MD, Miller KM. Pillow case. J Cataract Refract Surg 2005; 31:1825-1825. 3. Mand P, Miller KM. Pillows and tape. Ophthalmic Surg Lasers Imaging 2010; Mar 9:1-3. Kevin Miller, MD, Complicated cataract cases editor N ot all cataract patients are able to fully recline, which complicates surgery and increases the risk of intraoperative complications. For instance, some diseases of the heart, lungs, and spine may keep patients from being able to be completely supine. What should a surgeon do in these complex cases? As Teddy Roosevelt is often quoted as saying, "Do what you can, with what you have, where you are." Since 1996 we have been using a modified waiting room chair to accommodate patients with certain diseases such as chronic obstructive pulmonary disease, congestive heart failure, kyphosis, and some forms of arthritis. In 1994, Rimmer and Miller1 reported on a case in which they had to perform cataract surgery in a standing patient while using loupe magnification and illumination via headlamp. The patient was unable to lie down due to myotonic dystrophy and advanced interstitial lung disease. Since then, other cases of Waiting room chair (in upright position) altered by placing the back cushion on adjustable brackets. The legs were shortened and the head rest clamp was attached to the back of the chair. A spindle for counterbalance weight was attached to the base. performing cataract surgery while a patient was standing have been reported as well. Obviously, the seated or partially reclined position is not an ideal one for performing cataract surgery, especially since it creates an awkward angle to approach the patient with the operating microscope. This can, as we reported in a Journal of Cataract & Refractive Surgery article2 some years ago, result in great difficulty focusing on and manipulating tissue and instruments during the surgery and, with the head in an upright position, results in the shallowing of the anterior chamber, which then pushes the posterior capsule and vitreous forward—all thanks to gravity. In these cases, damaging the cornea and posterior capsule during phacoemulsification is a risk. For less than $200, we modified a waiting room chair so that patients would be able to stay in a seated position but place their head back for surgery. By moving the pad between the upright supports and placing an adjustable bracket on it, the waiting room chair can be reclined to put Front view of reclined chair with counterbalance weight between front legs the patient's head in the supine position. When we first constructed the chair, we used it to perform surgery on several patients with chronic obstructive pulmonary disease or claustrophobia, as well as one patient who had a chest wall deformity that caused respiratory difficulties. None of the patients experienced difficulties with the procedure, and all of the surgeries were without complications. In fact, surgeons found that the procedure was sometimes easier because the access to the head wasn't limited. Also, the patients were highly satisfied and they were more willing to have surgery in the contralateral eye. In one patient who suffered from severe claustrophobia, surgeons were able to do a full-face preparation. An aperture drape was used around the eye, and the patient did not suffer through the sensation of being closed in because surgeons avoided draping the rest of the face. Another patient with severe emphysema had an easier time breathing using the chair during surgery. She was able to rest her arms on the table during the procedure. Special accommodations usually have to be made for patients who have kyphosis, including putting them on a surgical stretcher and positioning them with pillows and rolled towels. The bed has to be placed into the Trendelenburg position, which means the patient lies in the supine position with his or her feet higher than the head by 15-30 degrees. If these patients are able to extend their necks, they are able to use the modified waiting room chair successfully. In fact, any patient who has trouble staying in a flat lying position could use this chair, which would make a complicated case that much easier. EW References Removable and adjustable head rest and head rest clamp Magnified view of back cushion adjustable brackets, with the chair back reclined Source (all): I. Howard Fine, MD 1. Rimmer S, Miller KM. Phacoemulsification in the standing position with loupe magnification and headlamp illumination.KJ Cataract Refract Surg 1994;K20: 353-354. 2. Fine IH, Hoffman RS,KBinstockKS. Phacoemulsification performed in a modified waiting room chair. J Cataract Refract Surg 1996;22:1408-1410. Contact information Fine: hfine@finemd.com