Side Saddle cataract surgery for patients unable to lie flat: learning from the past

PHACOSIT: A sitting phacoemulsification technique for patients unable to lie down flat during cataract surgery

Phacoemulsification is routinely performed with the patient lying supine on the surgical table with his or her head flat and facing the overhead microscope. This routine technique can be a challenge in medical conditions such as kyphosis, scoliosis, orthopnea, Meniere’s disease, and CNS abnormality. Some cardiovascular and respiratory conditions make the patients breathless when they lie down, whereas other neurological and spinal problem patients are also equally uncomfortable. The only reasonable solution to conduct surgery on a patient who cannot lie down flat on the operating table is to position them face to face in a sitting position. We describe an innovative phacoemulsification technique in a sitting position called “phacosit” in an 80-year-old wheelchair-bound female patient who was denied cataract surgery by other eye surgeons owing to her medical condition.

Avoiding Complications From Patient Positioning for Intraocular Surgery

Collaboration of the surgical and anesthesia teams for patient positioning is essential to assure patient comfort and safety, preventing systemic and ophthalmic complications. The goals and rationales of positioning for intraocular surgery are discussed including placing the head above the heart, elevating the chin, using a head rest that is sufficiently firm, maximizing anesthesia care team access and minimizing fire risk, and taping the patient's head to the operating table to reduce unexpected movement with intraocular injury.

Factors to be Considered when Performing Cataract Surgery in Patients Unable to Recline Flat

PURPOSE

Although phacoemulsification is routinely performed with the patient in a supine position, certain locomotor deformities and other severe ailments can lead to the inability of the patient to recline flat.

METHODS

The present article surveys publications and summarizes our own experience regarding positioning techniques during cataract surgery on patients unable to adopt a supine position.

RESULTS

The successful and effective performance of cataract surgery by phacoemulsification depend on the comfortable positioning of both the patient and the surgeon. In order to achieve the highest possible success rate in phacoemulsification surgery, optimal positioning of the patient and the operating microscope are essential. There are other features of pivotal importance, including the construction of the operating table, the anesthesia technique, and the surgical approach.

CONCLUSIONS

Surgeons often have to rely on their own imagination and experience in finding optimal positioning in order to perform effective and successful phacoemulsification surgery.

Standing phacoemulsification: a prospective audit of 20 consecutive cases

PURPOSE

To audit the surgical and postoperative complications and the visual outcomes of standing phacoemulsification and compare these with the results of conventional seated phacoemulsification.

SETTING

District general hospital, Sidcup, England.

DESIGN

Prospective comparative case series.

METHODS

This prospective audit comprised consecutive patients having standing phacoemulsification; a control group was drawn from all conventional phacoemulsification procedures on the same operating lists. One eye per patient was included. Demographic and surgical data, complications, and preoperative and postoperative visual acuity and intraocular pressure were recorded. Paired and unpaired t tests were used to compare mean values, and the chi-square test with Yates correction or the Fisher exact test was used to compare frequencies.

RESULTS

Twenty patients requiring standing phacoemulsification and 89 control patients were enrolled over a 32-month period. The 2 groups were similar in characteristics except the standing group was younger (68.2 years versus 78.0 years) (P<.005) and had a longer axial length (23.8 mm versus 23.1 mm) (P<.05). No patient in the standing group and 6% of patients in the control group had operative complications, although the difference between groups was not statistically significant. The rates of postoperative complications were comparable. Pinhole-corrected distance visual acuity was similar (6/12 or better: 90% in standing group and 94% in control group; 6/6 or better: 55% and 44%, respectively). Best-case analyses were similar between groups (6/12 or better, 100% versus 98%; 6/6 or better, 58% versus 51%).

CONCLUSIONS

Standing phacoemulsification was as safe as conventional seated surgery when performed by the same experienced surgeon. Visual results were excellent.

Cataract surgery in the patient that cannot lie flat

PURPOSE OF REVIEW

At times a patient requiring cataract surgery cannot be positioned flat rendering the case challenging. In addition, sometimes the medical condition that limits the patient's ability to lie supine also carries an increased risk of being placed under general anesthesia making topical anesthesia a safer option. The surgeon must often use ingenuity in positioning in order to carry out a successful surgery. This review will highlight different techniques employed for cataract surgery in a patient that cannot lie supine.

RECENT FINDINGS

There is a small amount of published literature describing techniques of cataract surgery in the patient who cannot lie supine. We hope to highlight the various techniques that have been described in the literature.

SUMMARY

Cataract surgery can become more complex when the patient cannot be positioned with their head flat on the operating table. With creative alterations to normal positioning, successful phacoemulsification can be executed.