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Phacoemulsification in a patient with marked cervical kyphosis
Phacoemulsification in a patient with marked cervical kyphosis Somdutt Prasad, MS, FRCSEd, Girish G. Kamath, MS, DNB, FRCSEd, FRCOphth, Russell P. Phillips, DO, FRCSEd, FRCOphth, MD ABSTRACT A patient with long-standing ankylosing spondylitis and chronic uveitis needed cataract extraction in his only eye. Extensive spinal deformities, including cervical kyphosis, prevented him from being positioned satisfactorily for surgery using a routine head-end or temporal position for the surgeon. The best possible position for surgery was achieved using an orthopedic operating table, which allowed the patient’s head to be reclined to a position of 60 degrees to the horizontal. Successful combined phacoemulsification and trabeculectomy was then performed, although the angle of approach for the surgeon and the operating microscope was awkward. J Cataract Refract Surg 2000; 26:1258 –1260 © 2000 ASCRS and ESCRS
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atients unable to recline present a challenge to the cataract surgeon. Various diseases and conditions can cause deformities such as kyphosis or torticollis, making it difficult to position the patient with the head in the usual position. Other patients cannot recline because of chronic obstructive pulmonary disease or congestive heart failure. Various authors have reported techniques to work around these problems. We report a case in which combined phacoemulsification and trabeculectomy was performed with the patient’s head positioned at a 60 degree inclination because of fixed cervical kyphosis.
Case Report A 43-year-old man had ankylosing spondylitis for the past 22 years. Since 1984, his mobility had deteriorated gradAccepted for publication October 16, 1999. From the Department of Ophthalmology, Arrowe Park Hospital, Wirral, United Kingdom. Reprint requests to Mr. Somdutt Prasad, Lecturer in Ophthalmology, Floor O, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom. E-mail: [email protected]; [email protected]. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
ually with progression of his kyphosis, stiffness of the low back, and contractures of the hips and knees. He had to give up his clerical job and had been wheelchair bound since 1988. Assessment showed fixed cervical kyphosis resulting in a chindown position, making the patient unable to lift his head (Figure 1). The thoracic region had marked kyphoscoliosis. He also had virtual fixation of hips in 40 degrees of flexion and adduction together with fixed flexion deformities in both knees. The patient had a long history of bilateral chronic uveitis, which had resulted in a phthisical right eye with no light perception. Visual acuity in the left eye was hand movements only with accurate light projection. Intraocular pressure, measured with a Tono-Pen as the patient could not be positioned at a slitlamp, was elevated. He had a dense nuclear sclerotic cataract with extensive posterior synechiae, precluding a view of the fundus. An ultrasound B-scan showed a flat retina with a posterior vitreous detachment. Medical treatment for his ophthalmic condition consisted of topical levobunolol, latanoprost, and ketorolac drops in the left eye and acetazolamide sustained-release tablets. Gradually, his vision deteriorated to the extent that the patient found it difficult to see food on his plate. He elected to have surgery at this stage. Surgery was performed using peribulbar anesthesia. At surgery, a 4-section orthopedic operating table (Smiths Industries Medical Systems, Eschman Equipment Division) was used to position the patient as well as possible. This table has 0886-3350/00/$–see front matter PII S0886-3350(00)00596-4
CASE REPORTS: PRASAD
Figure 1. (Prasad) Preoperative photograph of patient showing deformities, including cervical and thoracic kyphosis.
Figure 2. (Prasad) Position of patient on the operation table, with
4 movable sections and 360 degree top rotation. By raising the patient’s feet and lowering the head end of the table, it was possible to lower the patient’s head to an inclination of about 60 degrees from the horizontal (Figure 2). It was impossible to extend the patient’s neck or to recline him further. This created an abnormal angle of approach for the operating microscope and the surgeon (R.P.P.), who had to sit facing the patient (Figure 3). Combined phacoemulsification, intraocular lens (IOL) implantation, and trabeculectomy augmented with 5-fluorouracil was performed. After a fornix-based conjunctival flap was reflected in the temporal area, a scleral tunnel was constructed. Posterior synechias were released, and the pupil was stretched. As a capsulorhexis could not be completed, the surgeon converted to a can-opener capsulotomy. Phacoemulsification was completed, and a primary posterior capsulotomy was performed using an MVR blade. This was done to avoid the need for a laser capsulotomy in the future. An Allergan SI-40NB foldable silicone IOL was inserted in the bag. A 5-fluorouracil-enhanced trabeculectomy was performed at the same site. One month postoperatively, visual acuity had recovered to 6/60. The cornea was clear, with a deep anterior chamber, stable IOL, and functioning filtration bleb. Intraocular pressure was 14 mm Hg without pressure-lowering medication. A retinal examination showed extensive old vasculitic changes.
for patients with chronic obstructive pulmonary disease and claustrophobia. However, some patients cannot extend their necks because of fixed spinal deformities. In patients with moderate deformity, a temporal approach can offer a satisfactory solution,2 or it is possible to perform phacoemulsification with the surgeon standing.3 Phacoemulsification has been done using loupe magnification and illumination from a headlamp in the standing position in such a difficult case.4 Mackool demonstrated a technique in which phacoemulsification is performed with the patient in a sitting position, with the surgeon seated on a bench placed over the patient’s lower extremities (“Can Phacoemulsification Be Performed on a Sitting Patient?” video presented at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 1998). In such cases, phacoemulsification provides a closed-chamber technique that minimizes shallowing of the anterior chamber and forward move-
head reclined 60 degrees from the horizontal.
Discussion Chronic obstructive airway disease, congestive cardiac failure, certain arthritides, and other conditions can cause deformities such as kyphosis that make it impossible to position patients in a supine position for cataract surgery. Various techniques have been used to rectify this problem. Fine and coauthors1 used a modified chair to allow the patient to remain upright but permitting the head to be tilted backward in a hyperextended position
Figure 3. (Prasad) Position of the surgeon and operating microscope during surgery, showing the angle of approach.
J CATARACT REFRACT SURG—VOL 26, AUGUST 2000
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CASE REPORTS: PRASAD
ment of the iris–lens diaphragm and vitreous caused by the semiupright position of the head. Our patient presented a special situation as his extensive deformities resulted in a position in which the normal operating position at the head end, or a temporal approach, was not feasible. The use of an orthopedic table allowed different segments of the spine and limbs to be positioned in different planes. The awkward angle of approach for the surgeon and the operating microscope resulted in difficulty focusing and in manipulating instruments and tissues. This was rendered manageable by carefully positioning the patient, the head in particular, on the orthopedic operating table. Caution must be used in elderly patients and those with cardiovascular compromise as a position with the feet raised much higher than the head may not be tolerated.
1260
Most patients with spinal deformities, pulmonary disease, or cardiac failure can be positioned adequately for cataract surgery using a head-end or temporal approach. In exceptional circumstances, however, it is possible to perform phacoemulsification with the patient’s head in a semiupright position and the surgeon facing the patient.
References 1. Fine IH, Hoffman RS, Binstock S. Phacoemulsification performed in a modified waiting room chair. J Cataract Refract Surg 1996; 22:1408 –1410 2. Liu C. Phacoemulsification in a patient with torticollis (letter). J Cataract Refract Surg 1995; 21:364 3. Hunter LH. Standing while performing phacoemulsification (letter). J Cataract Refract Surg 1995; 21:111 4. Rimmer S, Miller KM. Phacoemulsification in the standing position with loupe magnification and headlamp illumination. J Cataract Refract Surg 1994; 20:353–354
J CATARACT REFRACT SURG—VOL 26, AUGUST 2000
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atients unable to recline present a challenge to the cataract surgeon. Various diseases and conditions can cause deformities such as kyphosis or torticollis, making it difficult to position the patient with the head in the usual position. Other patients cannot recline because of chronic obstructive pulmonary disease or congestive heart failure. Various authors have reported techniques to work around these problems. We report a case in which combined phacoemulsification and trabeculectomy was performed with the patient’s head positioned at a 60 degree inclination because of fixed cervical kyphosis.
Case Report A 43-year-old man had ankylosing spondylitis for the past 22 years. Since 1984, his mobility had deteriorated gradAccepted for publication October 16, 1999. From the Department of Ophthalmology, Arrowe Park Hospital, Wirral, United Kingdom. Reprint requests to Mr. Somdutt Prasad, Lecturer in Ophthalmology, Floor O, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom. E-mail: [email protected]; [email protected]. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
ually with progression of his kyphosis, stiffness of the low back, and contractures of the hips and knees. He had to give up his clerical job and had been wheelchair bound since 1988. Assessment showed fixed cervical kyphosis resulting in a chindown position, making the patient unable to lift his head (Figure 1). The thoracic region had marked kyphoscoliosis. He also had virtual fixation of hips in 40 degrees of flexion and adduction together with fixed flexion deformities in both knees. The patient had a long history of bilateral chronic uveitis, which had resulted in a phthisical right eye with no light perception. Visual acuity in the left eye was hand movements only with accurate light projection. Intraocular pressure, measured with a Tono-Pen as the patient could not be positioned at a slitlamp, was elevated. He had a dense nuclear sclerotic cataract with extensive posterior synechiae, precluding a view of the fundus. An ultrasound B-scan showed a flat retina with a posterior vitreous detachment. Medical treatment for his ophthalmic condition consisted of topical levobunolol, latanoprost, and ketorolac drops in the left eye and acetazolamide sustained-release tablets. Gradually, his vision deteriorated to the extent that the patient found it difficult to see food on his plate. He elected to have surgery at this stage. Surgery was performed using peribulbar anesthesia. At surgery, a 4-section orthopedic operating table (Smiths Industries Medical Systems, Eschman Equipment Division) was used to position the patient as well as possible. This table has 0886-3350/00/$–see front matter PII S0886-3350(00)00596-4
CASE REPORTS: PRASAD
Figure 1. (Prasad) Preoperative photograph of patient showing deformities, including cervical and thoracic kyphosis.
Figure 2. (Prasad) Position of patient on the operation table, with
4 movable sections and 360 degree top rotation. By raising the patient’s feet and lowering the head end of the table, it was possible to lower the patient’s head to an inclination of about 60 degrees from the horizontal (Figure 2). It was impossible to extend the patient’s neck or to recline him further. This created an abnormal angle of approach for the operating microscope and the surgeon (R.P.P.), who had to sit facing the patient (Figure 3). Combined phacoemulsification, intraocular lens (IOL) implantation, and trabeculectomy augmented with 5-fluorouracil was performed. After a fornix-based conjunctival flap was reflected in the temporal area, a scleral tunnel was constructed. Posterior synechias were released, and the pupil was stretched. As a capsulorhexis could not be completed, the surgeon converted to a can-opener capsulotomy. Phacoemulsification was completed, and a primary posterior capsulotomy was performed using an MVR blade. This was done to avoid the need for a laser capsulotomy in the future. An Allergan SI-40NB foldable silicone IOL was inserted in the bag. A 5-fluorouracil-enhanced trabeculectomy was performed at the same site. One month postoperatively, visual acuity had recovered to 6/60. The cornea was clear, with a deep anterior chamber, stable IOL, and functioning filtration bleb. Intraocular pressure was 14 mm Hg without pressure-lowering medication. A retinal examination showed extensive old vasculitic changes.
for patients with chronic obstructive pulmonary disease and claustrophobia. However, some patients cannot extend their necks because of fixed spinal deformities. In patients with moderate deformity, a temporal approach can offer a satisfactory solution,2 or it is possible to perform phacoemulsification with the surgeon standing.3 Phacoemulsification has been done using loupe magnification and illumination from a headlamp in the standing position in such a difficult case.4 Mackool demonstrated a technique in which phacoemulsification is performed with the patient in a sitting position, with the surgeon seated on a bench placed over the patient’s lower extremities (“Can Phacoemulsification Be Performed on a Sitting Patient?” video presented at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 1998). In such cases, phacoemulsification provides a closed-chamber technique that minimizes shallowing of the anterior chamber and forward move-
head reclined 60 degrees from the horizontal.
Discussion Chronic obstructive airway disease, congestive cardiac failure, certain arthritides, and other conditions can cause deformities such as kyphosis that make it impossible to position patients in a supine position for cataract surgery. Various techniques have been used to rectify this problem. Fine and coauthors1 used a modified chair to allow the patient to remain upright but permitting the head to be tilted backward in a hyperextended position
Figure 3. (Prasad) Position of the surgeon and operating microscope during surgery, showing the angle of approach.
J CATARACT REFRACT SURG—VOL 26, AUGUST 2000
1259
CASE REPORTS: PRASAD
ment of the iris–lens diaphragm and vitreous caused by the semiupright position of the head. Our patient presented a special situation as his extensive deformities resulted in a position in which the normal operating position at the head end, or a temporal approach, was not feasible. The use of an orthopedic table allowed different segments of the spine and limbs to be positioned in different planes. The awkward angle of approach for the surgeon and the operating microscope resulted in difficulty focusing and in manipulating instruments and tissues. This was rendered manageable by carefully positioning the patient, the head in particular, on the orthopedic operating table. Caution must be used in elderly patients and those with cardiovascular compromise as a position with the feet raised much higher than the head may not be tolerated.
1260
Most patients with spinal deformities, pulmonary disease, or cardiac failure can be positioned adequately for cataract surgery using a head-end or temporal approach. In exceptional circumstances, however, it is possible to perform phacoemulsification with the patient’s head in a semiupright position and the surgeon facing the patient.
References 1. Fine IH, Hoffman RS, Binstock S. Phacoemulsification performed in a modified waiting room chair. J Cataract Refract Surg 1996; 22:1408 –1410 2. Liu C. Phacoemulsification in a patient with torticollis (letter). J Cataract Refract Surg 1995; 21:364 3. Hunter LH. Standing while performing phacoemulsification (letter). J Cataract Refract Surg 1995; 21:111 4. Rimmer S, Miller KM. Phacoemulsification in the standing position with loupe magnification and headlamp illumination. J Cataract Refract Surg 1994; 20:353–354
J CATARACT REFRACT SURG—VOL 26, AUGUST 2000