Upright seated positioning enables phaco in high risk, challenging cases

The technique enables comfortable surgery for patients who cannot lie flat.

Face-to-face seated positioning made cataract surgery feasible for patients who were unable to lie flat or face the ceiling, a study found.

The technique is suitable for many patients with orthopedic, neurological, cardiac, respiratory or psychological conditions, according to the study authors.

“Basically, the supine position with the patient’s face pointing toward the ceiling is the best because it’s usually comfortable for the patient and it’s what the surgeon is used to,” Tom Eke, MD, FRCOphth, the corresponding author, said in an interview with Ocular Surgery News. “It’s best for everybody, if you can do it. But there are some patients who just can’t do that position. Often it’s an older patient who gets breathless when they lie flat and also has a bent neck due to spinal problems. But there are a lot of other people who can’t do the face-to-ceiling position for a variety of reasons like ankylosing spondylitis or neurodegenerative disorders.”

The technique, which differs only slightly from the standard method, involves a customary reclining surgical chair and an operating microscope that can be rotated from the vertical position, Dr. Eke said.

The study was published in the Journal of Cataract and Refractive Surgery.

Topical anesthesia preferred

The back of the surgical chair is elevated above horizontal and the microscope is rotated to face the patient. Dr. Eke said he either sits or stands, facing the patient. The actual surgery differs little from standard phacoemulsification, but the positioning means that the phaco incision is made in the lower part of the cornea. The positions of both patient and surgeon are carefully adjusted before scrubbing and draping begin.

“It’s really important to make sure that both the patient and the surgeon are happy with the position before surgery starts, and that they’ll both remain comfortable for what might be a long operation,” Dr. Eke said. He added that he reserves a double-length surgical time slot for these patients, because the positioning can often take as long as the surgery itself.

Tom Eke, MD, FRCOphth, demonstrates the principle of face-to-face upright-seated positioning for patients who cannot lie flat. If the patient needs to be extremely upright, it may be more comfortable for the surgeon to stand rather than sit, because the surgeon’s arms will be less outstretched. Image: Eke T

Dr. Eke said he prefers topical intracameral anesthesia without sedation for cataract surgery because it maximizes visualization.

“I much prefer topical anesthesia to eye blocks for all cataract surgery, simply because topical allows the eye to move,” he said. “The patient will always have their eye pointing toward the light. The eye is always on axis to the microscope. That makes it much easier because you get a good red reflex and everything is in the right plane. This is particularly useful for patients with ankylosing spondylitis, who can’t turn their head to face the microscope but can move the eye.”

Topical anesthesia is particularly suited to patients who need face-to-face positioning, according to Dr. Eke. “A block would just make surgery more difficult, because the eye would probably be pointing in the wrong direction,” he said.

Incision, chop technique

A clear corneal incision is made via an inferior, inferotemporal, inferonasal or temporal approach.

“The incision is in the bottom half, not the top half, because I’m sitting facing the patient,” Dr. Eke said. “Classically you might sit over the head of a supine patient and do the clear corneal incision at 12 o’clock, or 90·. But with this technique I’m more likely to make the incision at 6 o’clock, or 270·.” With experience, he said, it is usually possible to make the incision on the steep axis of astigmatism.

Bottle height is raised to compensate for the patient’s head being in a higher position. Dr. Eke usually uses his standard phaco-chop technique. “If the patient has to be really upright, then my arms will probably be more outstretched. In these cases, I prefer to do a divide-and-conquer with a straight second instrument, as it feels more controlled,” he said.

A straight second instrument can be removed more quickly than an angled chopper if the surgeon experiences arm strain or fatigue, Dr. Eke said.

Outcomes and complications

The published case series included 32 eyes of 28 patients. Surgery was performed successfully in 31 eyes. Posterior capsule rupture with a dropped nucleus occurred in one eye.

“The visual outcomes were all as expected. There were no postoperative complications attributable to the surgery or the position of incisions,” Dr. Eke said.

Surgery with upright seated positioning is more difficult than the standard supine technique, according to Dr. Eke.

“There’s no doubt that it is an unfamiliar and tricky thing to do. It’s not as easy as just doing the ordinary supine positioning,” he said. “I always warn the patients that there is an increased risk of having some sort of complication.”

To date, after performing 48 cases using the upright seated technique, Dr. Eke has experienced only one posterior capsule rupture.

“I want to get up to 52 cases and then I could say that my posterior capsular rupture rate was 1.92%, which is exactly the same as the published U.K. average for all cataract surgery,” he said. – by Matt Hasson

Reference:

• Lee RMH, Jehle T, Eke T. Face-to-face upright seated positioning for cataract surgery in patients who cannot lie flat. J Cataract Refract Surg. 2011;37(5):805-809.

• Tom Eke, MD, FRCOphth, can be reached at Department of Ophthalmology, Norfolk & Norwich University Hospital, Norwich NR4 7UY, United Kingdom; 44-0160-32-88-578; fax: 44-0160-32-88-261; email: tom.eke@nnuh.nhs.uk.
• Disclosure: Dr. Eke reported no financial relationship with any products or procedures named in this article.