Mitigating kyphosis-related challenges in cataract surgery: A simplified approach
Year: 2024
Type: article
Study design: Case Report
Abstract: Kyphosis is a pathological orthopedic condition characterized by a progressive and abnormal anterior convex curvature of the thoracic spine.[1] This condition gives rise to a structural deformity in which the spine exhibits an exaggerated rounding or bowing of the dorsal vertebral column. This anatomical aberration can clinically impact the physical and physiological aspects of skeletomuscular, cardiovascular, and respiratory functions.[1] Besides spine deformity, limited neck mobility and compromised lung capacity pose significant challenges for ophthalmic surgeons. Limited neck mobility can compromise intraocular instrumentation, and decreased lung capacity can elevate vitreous pressure. This can lead to increased operative time, intraoperative discomfort for the patient, risk of intraoperative complications, and poor postoperative outcome.[2] Several innovative methods have been published, such as the reverse Trendlenberg position with a pillow under the neck and head,[2] the use of a donut- and wedge-shaped head positioner,[3] the use of a 4-section orthopedic OT table,[4] enabling patients to maintain an upright seated posture with horizontal head positioning within a modified waiting room chair,[5] and laying the patients on their sides or doing inferior-approach phacoemulsification in the patient in a sitting position.[6] However, the effectiveness of each technique depends on the available circumstances, such as the patient’s physical status, the availability of technically advanced instruments in the operating room, and the surgeon’s experience. Here we report a 70-year-old female patient with marked kyphosis who came with a chief complaint of gradually progressive, painless diminution of vision in both her eyes for 2 years. On examination, she was found to have mature cataracts in both her eyes, and the right eye was planned for cataract surgery (small-incision cataract surgery (SICS)) first. There was no other systemic illness. During surgery, the patient was not able to maintain a proper supine posture due to her kyphosis [Fig. 1]. Therefore, we tried the following technique to accommodate her abnormal posture. Initially, we advised the patient to lie down on the OT table as best as she could. Following this, we introduced pillows under her neck, [Fig. 2] in such a way that (i) it would support her head so that her eyes would be in the proper horizontal alignment of the operative microscope, (ii) she could lie down comfortably for a prolonged time, and (iii) she could breathe easily.Figure 1: Photo of the patient showing severe kyphosisFigure 2: Pillows were introduced under the neck of the patient to achieve a suitable position for the head of the patientA supine position with the head in the horizontal plane, which is the routine position for cataract surgery, was comfortably achieved. Right-eye SICS was performed with a superior sclero-corneal tunnel approach in the usual manner with the surgeon in a standing position [Fig. 3]. The arrangement of pillows caused no inconvenience for the patient. The surgery went uneventful, and on postoperative day 1, the vision in the operated eye was 6/9p.Figure 3: An uneventful right-eye SICS was performed with a superior sclero-corneal tunnel approach in the usual manner with the surgeon in a standing positionDiscussion Kyphosis poses distinct challenges for eye surgeons, primarily due to the inability to position the head and neck horizontally, resulting in an obstructed view and hindering tissue manipulation and focus. Adjusting the operating table by tilting the head end downward and elevating the patient’s legs may compromise orbital venous return, potentially causing venous congestion and heightened posterior vitreous pressure during surgery. In addition, the patient’s limited pulmonary function may further impede orbital and jugular venous return, amplifying posterior vitreous pressure. Kyphosis-associated factors, including back tenderness, stiffness, and respiratory difficulties, can also negatively impact intraocular surgery. These considerations underscore the importance of careful planning and positioning adjustments to address the unique challenges of kyphotic patients undergoing eye surgery.[7] When patients are comfortable, they are more likely to cooperate and be able to endure an ophthalmic procedure, especially if it takes longer time than anticipated.[8] We encountered this problem and devised a simple, easy, yet cheap solution. Here, we have used two pillows to solve this problem. This can be used in any ophthalmic OT situated in developing countries/remote areas. This method seems suitable for any surgeon, irrespective of surgical experience. In addition, it does not need any technical assistance. Other approaches by experienced surgeons have also been reported, such as Fine et al.[5] innovatively adapted a conventional waiting room chair to facilitate seated surgery with a reclined head position. Even though this solution is helpful in patients with congestive heart failure or chronic obstructive lung disease, its applicability appears less pragmatic for patients afflicted with kyphosis as positioning challenges are inherent to this condition. Prasad et al.[4] successfully addressed the positioning challenge using an orthopedic operating table. However, this position is very unfamiliar for the patient as well as the ophthalmologist. Moreover, it is improbable that an orthopedic operating table will be found in an ophthalmic operating theatre. Ang et al.[9] introduced the face-to-face seated position for phacoemulsification with an inferior approach. This approach is inconvenient as it is not used routinely. In addition, it would require a highly experienced surgeon to perform an inferior phacoemulsification. Moreover, this approach would be very difficult to try for SICS, commonly used in India and other developing countries, due to frequent shallowing of the anterior chamber by gravity and difficulty in handling instrumentation leading to complications. We have found that using pillows to support a patient’s neck and spine allows both the patient and the surgeon to be comfortable without compromising a good surgical view. This can be tried for patients suffering from congestive cardiac failure, chronic obstructive pulmonary disease, or morbid obesity to provide comfort during surgery. Although our technique is easy, cost-effective, and frugal, it also has limitations. For example, this technique does not consider (i) different anatomical variations of kyphosis and its degree of severity; (ii) the patient’s anthropometric measurements: height and weight and their effect on the cushioning of the pillow; and (iii) other associated spine-related pathologies such as scoliosis, spondylosis, and spondylolisthesis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Authors: Nishant Maindargi, Anjali Khadia, Arpit Gupta
Institution: Aravind Eye Hospital
Language: English
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4403969479