Eyeworld

EW CATARACT 42 byline plus face Device focus "As my role model, I wanted to be as flexible as [Dr. Eke] is, so in my second year of training, he put me step-by-step in the position to operate with a bent microscope and elevated heads and/or upper bodies," Dr. Jehle said. "If you are trained to be flexible in terms of your position to the patient, it is relatively simple to convert. The most important thing is to do your surgery under [topical] anesthesia, as the eye will always stay on the axis and look toward the microscope, no matter where the light is coming from." Just how prevalent are cases in which a patient has to sit for the surgery? Dr. Eke said they're more common than one might think. "I did 4 people last week," Dr. Eke said when EyeWorld spoke to him in April. "One of them had muscular dystrophy, and he was on a breathing machine all the time. His wheelchair reclined back a little bit, so we did the surgery with him sitting in his wheelchair." Dr. Jehle said he has not per- formed too many cases with patients sitting up—maybe around 25 total. Drs. Eke and Jehle want their colleagues to know about and gain confidence in performing phaco on a patient who cannot lie flat. "There definitely is [a need]," Dr. Jehle said. "I think there are still … patients [who] have markedly reduced vision due to cataract, and no one is willing to operate on them as they are not able to lie flat and are not suitable for general anesthesia." EW References 1. Ang GS, et al. Face-to-face seated position- ing for phacoemulsification in patients unable to lie flat for cataract surgery. Am J Ophthal- mol. 2006;141:1151–52. 2. Lee RM, et al. Face-to-face upright seated positioning for cataract surgery in patients who cannot lie flat. J Cataract Refract Surg. 2011;37:805–09. 3. Pajuajis M, et al. Extreme face-to-face positioning for cataract surgery with patient seated upright in motorized wheelchair. J Cataract Refract Surg. 2013;39:804–05. 4. Moosavi R, et al. Phacoemulsification in patients unable to lie flat for cataract surgery: Face-to-face positioning with surgeon on the contralateral side. J Cataract Refract Surg. 2016;42: 495–97. Editors' note: Drs. Eke and Jehle have no financial interests related to their comments. Contact information Eke: tom.eke@nnuh.nhs.uk Jehle: tomjeh@gmail.com surgery remains the same, despite the difference in position. "It's often very straightfor- ward. Sit them up a bit and turn the microscope so that the surgeon is facing the patient. We always book plenty of time for me to move around and check that we've got a position I'm happy with and that the patient is happy with before we start surgery," Dr. Eke said. He insists on topical intra- cameral anesthesia because "this allows fine-tuning of the position by moving the patient, the chair, and the microscope, [so that] the eye will be pointing toward the micro- scope light. Topical intracameral anesthesia allows the eye to remain 'on axis,' which makes surgery easier and safer. You should be an above-average surgeon, but you don't need to be all that much above average." Still, Dr. Eke said surgeons need to be prepared to move around and do things differently. Dr. Eke concedes that some pa- tients are more difficult than others, and he will try "all the tricks in the book" to get the patient comfortable with his or her face more horizontal than vertical. Using this approach, he has not had to refuse cataract surgery to any patient who needs it. In the JCRS article, Dr. Eke and his coauthors state that if the pa- tient is seated at an angle of 30 to 80 degrees, for example, the microscope should be tilted between 45 and 60 degrees from vertical. The surgeon can either sit or stand to perform the operation. "The more upright the patient, the easier it is for the surgeon to stand instead of sit because the sur- geon's arms are less outstretched," he said. Despite his publications and presentations about performing phaco while the patient is sitting, Dr. Eke said he has been disappoint- ed that only a few surgeons have started doing it when faced with the challenge. "There's still a big unmet need," Dr. Eke said. "I get referred patients from around the country because colleagues don't have the equipment or experience to do this, but all you need is the right patient chair, mi- croscope, and the confidence to do things a bit differently." Thomas Jehle, MD, Meyer & Schliebs Augenärzte, Bremen, Germany, who trained in residency under Dr. Eke, said he learned to "do what's best for patients" in surgery. In some cases, this means having them sit up. stephensinst.com | +1.859.259.4924 Stephens Instruments | 2500 Sandersville Rd | Lexington KY 40511 USA Toll Free ( USA ) 800.354.7848 | Fax 859.259.4926 | info@stephensinst.com © 2016 Stephens Instruments. All rights reserved. LIFETIME WARRANTY 3 0 D A Y N O - R I S K T R I A L ISO 9001 ISO 13485 MICROSURE™ FEMTO TORIC S9-2070 S5-1535 ST5-7035 Stephens offers over 1,500 high-grade surgical stainless steel and titanium instruments, every one backed by a 30 day no-risk trial and lifetime warranty. You could pay more for your instruments, but why? Choose Stephens, trusted for over 40 years, and invest the savings in your practice—and your patients. The smart choice. Phaco continued from page 40

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