July 2012

 

CATARACT

 

Positioning problematic cataract patients for success


by Maxine Lipner Senior EyeWorld Contributing Editor

   

Source: Thinkstock/Comstock Images/Getty Images

Face-to-face approach promising for challenging cases

It's a standard part of cataract surgerythe 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, England, took a different approachhe 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 patient comfort allows, and the microscope is rotated away from the vertical so that the patient can gaze directly into the operating microscope light. "It helps a lot if the patient can turn his face or get his chin up to face the microscope. "Sometimes we can take 10 minutes getting the patient and myself 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 completely upright, but usually Dr. Eke 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 results. "I've had one capsule rupture out of 52, which did have a dropped nucleusa worst-case scenario," he said. Luckily the patient was a candidate 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 unfamiliar position and my arms are sticking forward a bit and sometimes I'm in a slightly uncomfortable position myself, but actually the numbers 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 concern that the position may result in an increased rate of endophthalmitis, 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 endophthalmitis 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 Meniere's disease, those with ankylosing 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 positioning is the only realistic alternative to blindness." The patients themselves give the face-to-face technique high marks. Dr. Eke conducted a survey of patient 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 positioning. All said that they would be happy to have the same positioning in the future."

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 positions. 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, involved a cataract patient with degenerative joint disease and severe kyphosis. Using 11 pillows beneath his buttocks and legs and three beneath 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 legs and buttocks, with a single towel and pillow beneath his head. With the patient's buttocks and legs raised in the air, his head was at a 35-40 degree down gaze, which could be sufficiently visualized with the operating room microscope. With these cases the preparation was half of the battle. "We found that once we got the patients in a comfortable position the case proceeded fairly uneventfully," he said. "It takes probably twice as much time to position them as to do the surgery, but once we got them there both of the patients were quite comfortable."

In another unusual case, Dr. Miller combined loupe magnification with headlamp illumination on a wheelchair-bound woman on facemask oxygen who was unable to recline. "I thought, 'She's going to be sitting straight uphow can I do this?'" Dr. Miller said. "We don't have microscopes that turn sideways, and even if we did she was a moving target [because] she was breathing so hard." Thinking on the fly, Dr. Miller taped her head to the back of the chair to help quell the movement. He then used a loupe to view the eye in conjunction with fiber optics illuminators usually reserved for plastics cases and performed the surgery while standing next to her. The results turned out well; at 6 months the woman had 20/20 acuity. While this case worked out well on the spot, Dr. Miller urges practitioners faced with these unusual cases to plan things out beforehand and get the patient on board. "The patient needs to know that this is not typical surgery, and there's a greater risk for problems," he said. "Most of them are highly motivated because when you can't see, you'll do what it takes."

Dr. Eke was impressed when he read about Dr. Miller's face-to-face positioning with loupe magnification. "Luckily, we have an operating microscope that rotates toward the horizontal, and this must be far easier than using loupes," he said. "Because my face-to-face patients are seated upright and comfortable, I have yet to find a patient who I cannot position for cataract surgery."

Editors' note: Drs. Eke and Miller have no financial interests related to this article.

Contact information

Eke: tom.eke@nnuh.nhs.uk
Miller: 310-206-9951, kmiller@ucla.edu

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