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Phacoemulsification in the standing position with loupe magnification and headlamp illumination
Phacoemulsification in the standing position with Ioupe magnification and headlamp illumination Steve Rimmer, M.D., Kevin M. Miller, M.D.
ABSTRACT A patient who could not recline from the seated position because of myotonic dystrophy and advanced interstitial lung disease presented to the UCLA Department of Ophthalmology Inpatient Consultation Service complaining of poor vision in both eyes as a result of corticosteroid-induced cataracts. We performed phacoemulsification and posterior chamber intraocular lens implantation in the standing position using magnifying loupes and fiber optic headlamp illumination. The excellent red reflex provided by the coaxial headlamp and the surgical control provided by bracing the operating hand against the cheek made this approach a viable option for this severely compromised patient. We discuss the surgical technique and its limitations. Key Words: cataract surgery, magnifying Ioupe, operating microscope, phacoemulsification
Before the advent of the operating microscope, cataract surgery was performed with loupes. In many Third World countries, loupes are still the primary source of optical magnification for cataract surgery. Phacoemulsification in industrialized nations is now performed almost exclusively under the high magnification and excellent optics of a coaxially illuminated operating microscope. Under appropriate circumstances, however, phacoemulsification with intraocular lens (IOL) implantation can be performed successfully with magnifying loupes and fiber optic headlamps.
SURGICAL TECHNIQUE A 44-year-old woman with myotonic dystrophy presented to the UCLA Department of Ophthalmology Inpatient Consultation Service complaining of poor vision and glare symptoms in both eyes. In addition to myotonic dystrophy, her medical problems included severe interstitial lung disease, obesity, cervical kyphosis, and hypothyroidism. She was wheelchair-bound and oxygen-dependent and unable to recline without becoming severely dyspneic. Ophthalmologic examination revealed bilateral dense posterior subcapsular cataracts. She was scheduled for cataract extraction in the right eye. The best corrected preoperative visual acuity of the eye was 20/100.
At the time of surgery, the patient was unable to recline more than 15 degrees from the vertical seated position without becoming severely dyspneic. With the addition of her cervical kyphosis, her head was completely vertical. In this seated position, she could not be positioned beneath the operating microscope. We elected to perform the surgery with magnifying loupes and fiber optic headlamps. Loupes with 1.8 times magnification and coaxial headlamp illumination allowed excellent visualization of the cataract in the red reflex. The surgeon and the assistant surgeon stood upright at the patient's right side during the procedure (Figure 1). Standard Nadbath and retrobulbar blocks were administered. A 3-clock-hour inferotemporal peritomy was carried out with Wescott scissors. A 6.5 mm long scleral tunnel was dissected 0.5 mm into clear cornea. A 15degree blade was used to create a paracentesis site at 11:30. The anterior chamber was entered through the scleral tunnel using a 3.2 mm keratome blade. Viscoelastic material was injected to re-form the anterior chamber. The anterior capsule was punctured with a bent 25-gauge needle, and a continuous curvilinear capsulorhexis was completed with Utrata forceps. Balanced salt solution was injected beneath the anterior capsule to hydrodissect the lens nucleus away from the cortex. The nucleus was found to be soft and was removed using a one-handed phacoemulsification technique. A small
From the Department of Ophthalmology, UCLA School of Medicine, and the Jules Stein Eye Institute, Los Angeles, California. Reprint requests to Kevin M. Miller, M.D., Jules Stein Eye Institute, 100 Stein Plaza, UCLA, Los Angeles, California 90024-7002. J CATARACT REFRACT SURG-VOL 20, MAY 1994
353
DISCUSSION
Fig. 1. (Rimmer) Standing to the patient's side and wearing magnifying loupes and fiber optic headlamps, the surgeon and assistant surgeon perform phacoemulsification and IOL implantation.
tear was produced in the posterior capsule during the phacoemulsification procedure, necessitating a limited anterior vitrectomy. The anterior capsulorhexis was preserved during the vitrectomy. A small amount of subincisional cortex was left in the eye after irrigation/ aspiration. Additional viscoelastic material was injected to re-form the anterior chamber, the entry wound was extended to 6.5 mm, and a three-piece posterior chamber IOL with a 6.5 mm optic was placed in the ciliary sulcus. The wound was closed with three interrupted 10-0 nylon sutures after the viscoelastic was removed. The patient's postoperative course was uneventful. On her most recent examination six months postoperatively, her visual acuity was 20/20, right eye, with a manifest refraction of -1.00 +0. 75 x 95.
354
Under appropriate circumstances, phacoemulsification and IOL implantation can be performed safely and successfully with loupes under headlamp illumination. This patient's cataract surgery could not have been performed any other way. If general anesthesia had been administered, it would have been difficult to wean the patient from the ventilator postoperatively. The key to the success of the surgery was the excellent red reflex provided by her well-dilated pupil and the soft nature of the cataract. Because of the quality of the red reflex, we were able to perform the capsulorhexis under low magnification. The nucleus was easy to emulsify. Undoubtedly, it would have been harder to perform a good capsulorhexis with a dull red reflex or to emulsify a hard nucleus with the limited magnification provided by loupes. Although our patient had a good visual result, some parts of the surgery were technically difficult to perform with magnifying loupes. The most difficult aspect ofthe surgery was adjusting to the head movements produced by her heavy breathing. Fortunately, with the inferotemporal approach, the cheek made an excellent wrist rest. Her heavy breathing resulted in positive vitreous pressure. Removal of the subincisional cortex was difficult because of the posterior capsule tear and the anterior bulge of the posterior capsule. Lens implantation and suture placement were performed easily. Most patients with chronic obstructive pulmonary disease, chronic congestive heart failure, and spinal deformities can be positioned comfortably beneath the operating microscope if an appropriate number of pillows is placed beneath the head and legs. Under exceptional circumstances, however, phacoemulsification can be performed with the surgeon standing at the patient's side wearing loupes and a fiber optic headlamp.
J CATARACT REFRACT SURG-VOL 20, MAY 1994
ABSTRACT A patient who could not recline from the seated position because of myotonic dystrophy and advanced interstitial lung disease presented to the UCLA Department of Ophthalmology Inpatient Consultation Service complaining of poor vision in both eyes as a result of corticosteroid-induced cataracts. We performed phacoemulsification and posterior chamber intraocular lens implantation in the standing position using magnifying loupes and fiber optic headlamp illumination. The excellent red reflex provided by the coaxial headlamp and the surgical control provided by bracing the operating hand against the cheek made this approach a viable option for this severely compromised patient. We discuss the surgical technique and its limitations. Key Words: cataract surgery, magnifying Ioupe, operating microscope, phacoemulsification
Before the advent of the operating microscope, cataract surgery was performed with loupes. In many Third World countries, loupes are still the primary source of optical magnification for cataract surgery. Phacoemulsification in industrialized nations is now performed almost exclusively under the high magnification and excellent optics of a coaxially illuminated operating microscope. Under appropriate circumstances, however, phacoemulsification with intraocular lens (IOL) implantation can be performed successfully with magnifying loupes and fiber optic headlamps.
SURGICAL TECHNIQUE A 44-year-old woman with myotonic dystrophy presented to the UCLA Department of Ophthalmology Inpatient Consultation Service complaining of poor vision and glare symptoms in both eyes. In addition to myotonic dystrophy, her medical problems included severe interstitial lung disease, obesity, cervical kyphosis, and hypothyroidism. She was wheelchair-bound and oxygen-dependent and unable to recline without becoming severely dyspneic. Ophthalmologic examination revealed bilateral dense posterior subcapsular cataracts. She was scheduled for cataract extraction in the right eye. The best corrected preoperative visual acuity of the eye was 20/100.
At the time of surgery, the patient was unable to recline more than 15 degrees from the vertical seated position without becoming severely dyspneic. With the addition of her cervical kyphosis, her head was completely vertical. In this seated position, she could not be positioned beneath the operating microscope. We elected to perform the surgery with magnifying loupes and fiber optic headlamps. Loupes with 1.8 times magnification and coaxial headlamp illumination allowed excellent visualization of the cataract in the red reflex. The surgeon and the assistant surgeon stood upright at the patient's right side during the procedure (Figure 1). Standard Nadbath and retrobulbar blocks were administered. A 3-clock-hour inferotemporal peritomy was carried out with Wescott scissors. A 6.5 mm long scleral tunnel was dissected 0.5 mm into clear cornea. A 15degree blade was used to create a paracentesis site at 11:30. The anterior chamber was entered through the scleral tunnel using a 3.2 mm keratome blade. Viscoelastic material was injected to re-form the anterior chamber. The anterior capsule was punctured with a bent 25-gauge needle, and a continuous curvilinear capsulorhexis was completed with Utrata forceps. Balanced salt solution was injected beneath the anterior capsule to hydrodissect the lens nucleus away from the cortex. The nucleus was found to be soft and was removed using a one-handed phacoemulsification technique. A small
From the Department of Ophthalmology, UCLA School of Medicine, and the Jules Stein Eye Institute, Los Angeles, California. Reprint requests to Kevin M. Miller, M.D., Jules Stein Eye Institute, 100 Stein Plaza, UCLA, Los Angeles, California 90024-7002. J CATARACT REFRACT SURG-VOL 20, MAY 1994
353
DISCUSSION
Fig. 1. (Rimmer) Standing to the patient's side and wearing magnifying loupes and fiber optic headlamps, the surgeon and assistant surgeon perform phacoemulsification and IOL implantation.
tear was produced in the posterior capsule during the phacoemulsification procedure, necessitating a limited anterior vitrectomy. The anterior capsulorhexis was preserved during the vitrectomy. A small amount of subincisional cortex was left in the eye after irrigation/ aspiration. Additional viscoelastic material was injected to re-form the anterior chamber, the entry wound was extended to 6.5 mm, and a three-piece posterior chamber IOL with a 6.5 mm optic was placed in the ciliary sulcus. The wound was closed with three interrupted 10-0 nylon sutures after the viscoelastic was removed. The patient's postoperative course was uneventful. On her most recent examination six months postoperatively, her visual acuity was 20/20, right eye, with a manifest refraction of -1.00 +0. 75 x 95.
354
Under appropriate circumstances, phacoemulsification and IOL implantation can be performed safely and successfully with loupes under headlamp illumination. This patient's cataract surgery could not have been performed any other way. If general anesthesia had been administered, it would have been difficult to wean the patient from the ventilator postoperatively. The key to the success of the surgery was the excellent red reflex provided by her well-dilated pupil and the soft nature of the cataract. Because of the quality of the red reflex, we were able to perform the capsulorhexis under low magnification. The nucleus was easy to emulsify. Undoubtedly, it would have been harder to perform a good capsulorhexis with a dull red reflex or to emulsify a hard nucleus with the limited magnification provided by loupes. Although our patient had a good visual result, some parts of the surgery were technically difficult to perform with magnifying loupes. The most difficult aspect ofthe surgery was adjusting to the head movements produced by her heavy breathing. Fortunately, with the inferotemporal approach, the cheek made an excellent wrist rest. Her heavy breathing resulted in positive vitreous pressure. Removal of the subincisional cortex was difficult because of the posterior capsule tear and the anterior bulge of the posterior capsule. Lens implantation and suture placement were performed easily. Most patients with chronic obstructive pulmonary disease, chronic congestive heart failure, and spinal deformities can be positioned comfortably beneath the operating microscope if an appropriate number of pillows is placed beneath the head and legs. Under exceptional circumstances, however, phacoemulsification can be performed with the surgeon standing at the patient's side wearing loupes and a fiber optic headlamp.
J CATARACT REFRACT SURG-VOL 20, MAY 1994