A simple way to achieve the routine position for phacoemulsification in a patient with marked thoracic kyphosis.

PURPOSE: To introduce a simple way for achieving the routine position for phacoemulsification in a patient with a marked thoracic kyphosis. CASE REPORT: A 74-year-old man with marked thoracic kyphosis and visually significant cataracts presented for surgery; he was unable to lie flat due to the severe deformity. The best possible surgical position was achieved by placing a chair with an adjustable top between a standard operating table and another small table. The wheels of the table and the chair were securely immobilized by adhesive tape. The space between the operating table and the small table was filled with rolled towels and covered with a blanket. The patient lay down with his head placed on the small table while the kyphotic portion of his thorax fitted into the free space between the small table and the operating table. The variable top of the chair allowed adjusting the space in order to accommodate his kyphotic thorax. Successful temporal approach phacoemulsification was performed comfortably while the patient lay in the standard position required for cataract surgery.
CONCLUSION: It is possible to position patients with thoracic problems on a standard operating table using readily available equipment in the operating theater.

INTRODUCTION

The first step in cataract surgery is to ensure that both the patient and surgeon are comfortably positioned. Phacoemulsification is routinely performed with the patient lying supine with the head flat. Anatomical deformities such as kyphosis make it difficult to position the patient in the usual position. Some techniques have been reported for cataract surgery in patients with such anatomical problems.1–4 Herein, we report a case of severe kyphosis who underwent phacoemulsification with his head positioned flat using a chair and a small table as adjuncts to a standard operating table.

CASE REPORT

A 74-year-old man with marked congenital thoracic kyphosis presented for cataract surgery (Fig. 1). He had dense nuclear sclerotic cataracts with best-corrected visual acuity of counting fingers in both eyes. Because of a fixed thoracic kyphosis, he was unable to lie flat for surgery. Therefore we adopted the following technique to accommodate his abnormal posture. A chair with an adjustable round top was placed between the standard operating table and a smaller table, such that the kyphotic portion of the thorax fitted into this free space.The operating table was set to the level of the small table and the variable top of the chair was adjusted to accommodate the kyphotic thorax (Fig. 2). The wheels of the table and the chair were securely immobilized by taping. The space between the operating table and the small table was filled with rolled towels and covered with a blanket, and the patient was reclined comfortably (Fig. 3). Supine position with the head in horizontal plane, the routine position for cataract surgery, was comfortably achieved and temporal approach phacoemulsification was performed on the left eye in the usual manner. The small table and chair caused no inconvenience for the surgeon. One month after surgery, visual acuity in the left eye was 20/25 and the patient was scheduled for cataract surgery in his right eye.

Figure 1

The patient with marked thoracic kyphosis.

Figure 2

To provide a free space for the kyphotic portion of the thorax, a chair and a small table were used in conjunction to the standard operating table.

Figure 3

Side view: the patient’s head is on the small table, the kyphotic thorax is located in the free space between the small table and the operating table while the tip of the kyphosis rests on top of the chair.

DISCUSSION

Patients unable to recline properly present a challenge for cataract surgery. A comfortable patient is more likely to cooperate and is more liable to tolerate the procedure in case it takes longer than expected. Various techniques have been reported to solve positioning problems in these patients. We have presented our approach to this problem in a patient with thoracic kyphosis who was unable to lie supine for cataract surgery. We used an ordinary chair and table as adjuncts to a standard operating table. Other approaches for positioning patients who cannot recline have been reported. Fine et al1 modified a standard waiting room chair which allowed patients to be seated during surgery,with their heads tilted back. This approach may be suitable for patients with congestive heart failure or chronic obstructive lung disease, but seems impractical for patients with thoracic kyphosis. Prasad et al2 solved the positioning problem by using an orthopedic operating table. In this method the patient was placed in an unfamiliar position which may be uncomfortable,furthermore this particular type of orthopedic table may not be available in ophthalmic operating theaters. Gordon et al3 reported a case of severe kyphosis who underwent cataract surgery safely by padding the operating table with pillows and positioning the operating table in maximum reverse Trendelenburg position in order to obtain a good red reflex.Caution must be taken in elderly patients and those with cardiovascular compromise, as such a position may not be tolerated. Ang et al4 introduced the face-to-face seated position for phacoemulsification with an inferior approach.Inferior approach phacoemulsification is unconventional and positioning a patient in a seated or partially reclined position creates an abnormal angle of approach for the operating microscope, resulting in difficult focusing and surgical maneuvers. Although they reported no difficultly in performing phacoemulsification,gravity may cause shallowness of the anterior chamber, moving the posterior capsule and the vitreous body forward. In our approach, we used simple equipment readily available in ophthalmic surgical theaters with the patient lying in a familiar position. We recommend this technique for patients with thoracic kyphosis who cannot lie supine.