EyeWorld Asia-Pacific September 2013 Issue

48 EWAP CAtArACt/IOL September 2013 Modifying chair may help in complicated cases by I. Howard Fine, MD Creative solution to challenging condition N ot all cataract patients are able to fully recline, which complicates surgery and increases the risk of intraoperative complications. For instance, some diseases of the heart, lungs, and spine may keep patients from being able to be completely supine. What should a surgeon do in these complex cases? As Teddy Roosevelt is often quoted as saying, “Do what you can, with what you have, where you are.” Since 1996 we have been using a modified waiting room chair to accommodate patients with certain diseases such as chronic obstructive pulmonary disease, congestive heart failure, kyphosis, and some forms of arthritis. In 1994, Rimmer and Miller1 reported on a case in which they had to perform cataract surgery in a standing patient while using loupe magnification and illumination via headlamp. The patient was unable to lie down due to myotonic dystrophy and advanced interstitial lung disease. Since then, other cases of performing cataract surgery while a patient was standing have been reported as well. Obviously, the seated or partially reclined position is not an ideal one for performing cataract surgery, especially since it creates an awkward angle to approach the patient with the operating microscope. This can, as we reported in a Journal of Cataract & Refractive Surgery article2 some years ago, result in great difficulty focusing on and manipulating tissue and instruments during the surgery and, with the head in an upright position, results in the shallowing of the anterior chamber, which then pushes the posterior capsule and vitreous forward—all thanks to gravity. In these cases, damaging the cornea and posterior capsule during phacoemulsification is a risk. For less than US$200, we modified a waiting room chair so that patients would be able to stay in a seated position but place their head back for surgery. By moving the pad between the upright supports and placing an adjustable bracket on it, the waiting room chair can be reclined to put the patient’s head in the supine position. When we first constructed the chair, we used it to perform surgery on several patients with chronic obstructive pulmonary disease or claustrophobia, as well as one patient who had a chest wall deformity that caused respiratory difficulties. None of the patients experienced difficulties with the procedure, and all of the surgeries were without complications. In fact, surgeons found that the procedure was sometimes easier because the access to the head wasn’t limited. Also, the patients were highly satisfied and they were more willing to have surgery in the contralateral eye. In one patient who suffered from severe claustrophobia, surgeons were able to do a full-face preparation. An aperture drape was used around the eye, and the patient did not suffer through the sensation of being closed in because surgeons avoided draping the rest of the face. Another patient with severe emphysema had an easier time breathing using the chair during surgery. She was able to rest her arms on the table during the procedure. Waiting room chair (in upright position) altered by placing the back cushion on adjustable brackets. The legs were shortened and the head rest clamp was attached to the back of the chair. A spindle for counterbalance weight was attached to the base. Front view of reclined chair with counterbalance weight between front legs Removable and adjustable head rest and head rest clamp Magnified view of back cushion adjusta- ble brackets, with the chair back reclined Source (all): I. Howard Fine, MD Special accommodations usually have to be made for patients who have kyphosis, including putting them on a surgical stretcher and positioning them with pillows and rolled towels. The bed has to be placed into the Trendelenburg position, which means the patient lies in the supine position with his or her feet higher than the head by 15-30 degrees. If these patients are able to extend their necks, they are able to use the modified waiting room chair successfully. In fact, any patient who has trouble staying in a flat lying position could use this chair, which would make a complicated case that much easier. EWAP references 1. Rimmer S, Miller KM. Phacoemulsification in the standing position with loupe magnification and headlamp illumination. J Cataract Refract Surg . 1994; 20: 353-354. 2. Fine IH, Hoffman RS, Binstock S. Phacoemulsification performed in a modified waiting room chair. J Cataract Refract Surg . 1996;22:1408-1410. Contact information Fine: hfine@finemd.com