Sohail T, Pajaujis M, Crawford SE, Chan JW, Eke T.
Face-to-face upright seated positioning for cataract surgery in patients who cannot lie flat. Patients who cannot lie flat for cataract surgery should be warned that their surgery may have a higher risk of surgical complications. Shortening the microscope can also help to make it more comfortable for the surgeon: many microscopes may have camera sections, filters or other attachments- if these can be safely removed, it can make surgery easier (and therefore quicker and safer). It may be necessary to purchase new eyepieces (short, and can be rotated upwards through a large range). The microscope should be able to rotate forward. The patient chair should be adaptable to various positions. Surgeons wishing to try face-to-face surgery should be already experienced in cataract surgery with topical anesthesia. For some microscopes, a rotation by this amount will mean that the surgeon's arms are uncomfortably high or too far outstretched: this can usually be overcome by using short eyepieces that can be rotated upward. For most face-to-face patients, the microscope needs to be 40-60 degrees away from vertical. It is necessary to have a microscope that can be rotated forward, so it faces more horizontally than vertically. Many types of surgical chairs allow this position, and this method can be used to operate on patients who cannot transfer from their wheelchair. This principle is particularly useful for face-to-face surgery. Topical (topical-intracameral) anesthesia allows the patient to direct their gaze toward the microscope, thus keeping the eye 'on axis' for easier cataract surgery. It's worth spending time to ensure that patient and surgeon should remain comfortable for what may be a longer operation. Sometimes it may help to rotate the bed so the patient is facing toward the surgeon. Because the eye is higher above the floor than normal, the infusion bottle height should be raised accordingly.įace-to-face positioning is easier if the patient can be more supine, extend their neck, or turn their face/chin-up toward the microscope. Cataract surgery is done through an incision in the lower half of the cornea: right-handed surgeons may find it easiest to use a temporal incision (0 degrees) for a left eye and inferior incision (270 degrees) for a right eye. The microscope is rotated forwards to face the eye, and the surgeon sits (or stands) facing the patient. For face-to-face surgery, the patient sits upright and comfortable on the surgical chair. This is actually the commonest reason for an inability to position supine: a combination of problem 1 and problem 2. Patient cannot have chest flat, and cannot extend neck: Face-to-face upright seated positioning Many types of surgical chairs will allow for this position. Usually this means a 'standing temporal' approach, though this is not always necessary. A surgeon of average height will find that they cannot comfortably operate from the seated position, and it is much easier for the surgeon to stand. The head-rest is adjusted so that the patient can extend the neck, and look up to the overhead microscope. If severe orthopnoea, the patient may need to be seated upright. Typical examples would be the patient with orthopnoea (e.g heart failure or severe COPD), but has a flexible spine so they can extend the neck. Patient cannot have chest flat, but has flexible neck: Patient seated upright, surgeon standing Many types of surgical chairs will tip back to the Trendelenburg position. Because the head is lower than the rest of the body, venous engorgement can be expected, This may cause vitreous bulge or increased posterior pressure: for cataract surgery, this can be compensated for by raising the height of the infusion bottle. It is a useful option for surgeons who do not have access to a microscope that rotates forward (see option 3). It only works for patients who can tolerate this position therefore it is not suitable for many older patients who may have coexistent orthopnoea. This is called the 'Trendelenburg position'. If the patient is able, they can be positioned in a chair which is then tipped backward, so that the patient's feet are above their head. Typical examples would be anklyosing spondylitis or other problems causing a kyphosis of the spine. Options Patient has bent spine/neck, otherwise well: Trendelenburg position
1.2 Patient cannot have chest flat, but has flexible neck: Patient seated upright, surgeon standing.1.1 Patient has bent spine/neck, otherwise well: Trendelenburg position.
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