December 2009

 

OPHTHALMOLOGY NEWS

 

Changing your surgical approach


by Matt Young EyeWorld Contributing Editor

   

A parachute harness is not the most comfortable equipment to wear—unless you’re a hunchback in need of cataract surgery. Researchers have developed a new technique to operate on cataract patients with severe kyphosis so that their head is horizontal and they are comfortable. “The legs are lifted into the Trendelenburg position, and the patient is supported with straps similar to those of a parachute,” according to a report by Thomas A. Oetting, M.D., professor of clinical ophthalmology, University of Iowa, Iowa City, Iowa; chief, Eye Service, and deputy director, Surgery Service, VA Medical Center, Iowa City, and colleagues. “This technique is similar to that described by others but has the additional security of the parachute-like straps.”

No fear of ejection

For some patients, lying down might be the simplest part of surgery, but not for others. Pulmonary problems in some patients have necessitated that they remain in an upright position for surgery. Some surgeons have even stood to operate on kyphosis patients. Others have used numerous pillows and a Trendelenburg technique. “This improves the position, but we suggest adding the parachute-like straps to keep the patient secure on the operating table,” Dr. Oetting reported in the August 2009 issue of the Journal of Cataract & Refractive Surgery. “The parachute-like harness straps place the patient in an ideal position, require minimal adjustment of the surgical technique, and maintain a secure and comfortable patient position for the duration of the procedure.”

Key factors to performing this technique successfully include: • An operating table, allowing the kyphosis patient’s legs to be lifted above the head.

• Several pieces of foam for support (of the head, neck, shoulders, and knees).

• Velcro surgical straps. These are “secured above the patient’s shoulder(s) and crossed over the chest, similar to the straps in a parachute harness. Compared with tape, the Velcro straps provide great support with little risk of skin damage, stretch, or breakage,” Dr. Oetting noted. • Positioning of the surgeon. “[The] surgeon must sit superiorly as the head of the bed is too low to allow a temporal approach,” Dr. Oetting noted. By using these instruments, the patient can be positioned into an extreme Trendelenburg position so that the head is horizontal in a traditional fashion.

Case studies

In one case, a 65-year-old man with kyphosis presented for cataract surgery, undergoing his operation using the earlier-described technique. “Because of limited leg room under the head and neck supports, the surgeon sat in a superior position,” Dr. Oetting reported. “A clear corneal superotemporal wound was made, and the phacoemulsification probe was placed in the left hand as the patient had a large brow.”

The second eye was operated upon years later, with a slight modification in technique. “When the cataract in the right eye progressed several years later, a retrobulbar block was used and the patient was positioned as for the left eye using the harness over one shoulder only,” Dr. Oetting reported. “In this case of a right eye, the superotemporal wound construction allowed the phacoemulsification handpiece to be held in the right hand.”

There were no complications. “Although some jugular distension was noted, no significant posterior pressure from the reverse Trendelenburg position was noted,” Dr. Oetting reported.

In another case of a 79-year-old man, the parachute technique again was used. “The surgeon [was] seated superiorly to facilitate a superotemporal wound and placement of the phacoemulsification handpiece in the right hand,” Dr. Oetting noted. “The horizontal position facilitated this complex case, which required posterior synechiolysis and placement of a Malyugin ring to maintain pupil dilation throughout the otherwise uncomplicated case.”

John D. Sheppard, M.D., professor of ophthalmology, microbiology, and immunology, Eastern Virginia Medical School, Norfolk, Va., said he has used a similar method to position patients with severe kyphosis during cataract surgery. “Since the patient’s chin is sticking down into his chest, the only way is to position the rest of the body pointing up so that the patient looks like a V,” Dr. Sheppard said. “This may or may not be comfortable,” but it’s what works, he said. Dr. Sheppard added that he also used straps to secure the patient, and that every operating table has these. At times, Dr. Sheppard also has had to stand up while performing surgery on kyphosis patients. “I did that a couple months ago,” Dr. Sheppard said. “The patient was a 90-year-old woman with severe stenosis. The biggest difficulty while standing is using the foot pedals.”

Editors’ note: Dr. Oetting has no financial interests related to this study. Dr. Sheppard has no financial interests related to his comments.

Contact information

Oetting: thomas-oetting@uiowa.edu
Sheppard: 757-622-2200, docshep@hotmail.com

Changing your surgical approach Changing your surgical approach
Ophthalmology News - EyeWorld Magazine
283 110
216 144
,
2017-04-20T06:35:41Z
True, 12