From the Jules Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Kevin M. Miller, MD, Jules Stein Eye Institute, 100 Stein Plaza, UCLA, Los Angeles, CA 90095-7002.
Adequate positioning of patients during cataract surgery is necessary to optimize surgical outcomes and maximize the comfort of the patient and surgeon. Some patients cannot be positioned under an operating microscope using traditional methods. In these instances, alternative techniques must be employed to achieve good outcomes. In this report, we describe a patient with a severe neck deformity causing near-total flexion who was comfortably positioned for cataract surgery using a standard cataract surgical chair that reclines into a table and plenty of pillows and tape.
A 76-year-old man with a visually significant cataract in his right eye came to the Jules Stein Eye Institute at UCLA in 2007 requesting cataract surgery. He had ankylosing spondylitis and a severe neck deformity. He had injured his neck after a fall in the 1980s and had a facedown posture at the time of presentation. He was scheduled for cataract surgery elsewhere, but the surgery was cancelled in the operating room because he could not be positioned beneath the operating microscope.
In the examination room, the patient could not position himself at the chin rest of a slit lamp biomicroscope. External examination demonstrated a clear deformity of the neck in a rigid head down posture (Fig. 1). The patient was unable to extend his neck, even with great effort. There was no significant kyphoscoliosis and his back was relatively supple.
Figure 1. This View Shows a Patient with a Severe Neck Deformity as He Appeared in the Examining Room.
His best-corrected visual acuity at the time of presentation was counting fingers at 6 feet in the right eye and 20/70 in the left eye. Retinoscopy was the best method to view the cataracts since a portable slit lamp was not available. Both eyes had moderately dense nuclear and cortical cataracts.
Surgery was scheduled for the right eye. Special measures were taken to handle his neck deformity. First, approximately 25 to 30 pillows were placed beneath his legs and buttocks. Then, a single pillow and towel were placed beneath his head. This arrangement lifted the patient’s torso, buttocks, and legs high into the air, so that he had an approximately 50 to 60° incline to the table (Fig. 2). His head was in a 35 to 40° down-gaze, which was adequate to visualize his eye beneath the operating microscope (Fig. 3). Numerous long strips of tape were used to secure the pillows and patient so that they would not roll, shoot out, nor fall off the table. After recovery, the best-corrected visual acuity of the patient’s operated right eye was 20/20. He was comfortable during surgery and pleased with the result.
Figure 2. This View Shows the Patient on an Operating Table in the Trendelenburg Position. 25 to 30 Pillows Supported the Patient’s Torso and Buttocks While 1 Pillow and 1 Towel Supported His Head and Neck.
Figure 3. This View Shows the Patient Under a Sterile Drape Just Before the Start of Cataract Surgery.
This case example demonstrates that patients with extreme neck deformities can be positioned successfully for cataract surgery. We recommend using as many pillows as needed to achieve the body angle necessary to get the patient’s head under the operating microscope. The head does not have to be flat to the plane of the microscope objective, although this is ideal. It just has to be flat enough to give the surgeon an adequate view. The patient and pillows should be secured to the operating table with cloth tape that will not release nor tear easily. These two simple tools can turn a seemingly impossible situation into one that can be managed with little extra effort.
Positioning for cataract surgery must be tailored to the individual. If a patient is uncomfortable at the start of surgery, he or she will often be uneasy or fidgety as surgery progresses, thereby compromising the operative view and increasing the risk of surgical complications. We routinely place a pillow below the knees of our patients to relieve pressure on the lower spine, a folded towel or two beneath the head to relieve neck tension, and as many blankets as needed to keep the patient warm. During longer operations, we allow patients the opportunity to stretch and move their legs.
The elevated intraocular pressure that results from positioning the center of the mass of the body above the head can be counteracted by raising the irrigating bottle appropriately, and by assuring relatively watertight incisions.
Various comorbidities may complicate positioning. Gordon and coauthors1 described a patient with severe kyphosis who was positioned using pillows and tape. The patient in their report was able to lift his head to 30° below the horizontal, which is a greater range of motion than we observed with our patient. The surgeons were able to position the patient in their report with “only” 14 pillows, 11 under the buttocks and torso and 3 under the head. The patient in this case was a greater challenge given his restricted range of neck motion.
While patients with back and neck deformities can often be positioned using pillows and tape, these tools might be inappropriate in other settings. Patients at risk for high vitreous pressure when placed in the Trendelenburg position, such as the obese, may not be suitable candidates. Mansour and Al-Dairy2 described a standing phacoemulsification technique for morbidly obese patients utilizing the reverse Trendelenburg position. They were able to perform surgery by placing the operating microscope at maximum upward position and at minimum magnification, and by using a one-handed and one-legged phacoemulsification technique. Rimmer and Miller3 described a patient with severe dyspnea from interstitial lung disease and myotonic dystrophy who was unable to recline from the vertically upright seated position. They were able to perform phacoemulsification and posterior chamber intraocular lens implantation in the standing position using fiber optic headlamps and magnifying loupes. Ang, Ong and Eke4 described a method of face-to-face positioning for a patient with chronic obstructive pulmonary disease who became breathless when reclined beyond 45°. They placed the patient in a semirecumbent position and rotated a ceiling-mounted microscope 60° from the vertical. Their surgery was performed with the surgeon sitting on the patient’s right side, operating at arms length using an inferior approach. Operating at this distance may prove to be uncomfortable for the surgeon.
The above techniques may be associated with increased risk based solely on the fact that they are novel approaches. However, these methods allow for cataract removal in difficult cases. It is beneficial to consider cataract surgery relatively earlier in patients with positioning handicaps as the difficulty and complications of surgery increase as the nucleus becomes denser. The risk of complications can be reduced if an experienced surgeon performs the surgery.
- Gordon MI, Rodriquez AA, Olson MD, Miller KM. Pillow Case. J Cataract Refract Surg. 2005; 31:1824–1825 doi:10.1016/j.jcrs.2005.01.019 [CrossRef]
- Mansour AM, Al-Dairy M. Modifications in cataract surgery for the morbidly obese patient. J Cataract Refract Surg. 2004; 30: 2265–2268 doi:10.1016/j.jcrs.2004.02.088 [CrossRef]
- Rimmer S, Miller KM. Phacoemulsification in the standing position with loupe magnification and headlamp illumination. J Cataract Refract Surg. 1994; 20:353–354
- Ang GS, Ong JM, Eke T. Face-to-face positioning for phacoemulsification in patients unable to lie flat for cataract surgery. Am J Ophthalmol. 2006; 141:1151–1152 doi:10.1016/j.ajo.2006.01.036 [CrossRef]