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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 58  |  Issue : 2  |  Page : 119-121

Small-incision cataract surgery in a case of cervicothoracic kyphosis: A surgical challenge


1 Department of Ophthalmology, Neuro-Ophthalmolgy and Pediatric Ophthalmmology, Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Chennai, Tamil Nadu, India
2 Department of Squint, Neuro-Ophthalmolgy and Pediatric Ophthalmmology, Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Chennai, Tamil Nadu, India

Date of Submission03-Mar-2020
Date of Acceptance21-Apr-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. A Anuradha
Department of Squint, Neuro-Ophthalmolgy and Pediatric Ophthalmmology, Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Egmore, Chennai - 600 008, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_15_20

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  Abstract 


Positioning of patient and adjusting the microscope to achieve adequate field of view is crucial for a comfortable cataract surgery. When there are hindrances to such an ideal positioning, several strategies have to be adopted to facilitate the surgery. Kyphosis, characterized by excessive curvature of the thoracic spine is one such condition. This case report illustrates an elderly male presenting with severe visual impairment and circumstances making surgery inevitable. The emphasis is to understand the ingenuine measures to be taken to tackle the challenges faced in such a scenario.

Keywords: Challenges, kyphosis, small incision cataract surgery


How to cite this article:
Senthil Kumar NK, Malarvizhi R, Anuradha A, Jayalatha J, Sheela S. Small-incision cataract surgery in a case of cervicothoracic kyphosis: A surgical challenge. TNOA J Ophthalmic Sci Res 2020;58:119-21

How to cite this URL:
Senthil Kumar NK, Malarvizhi R, Anuradha A, Jayalatha J, Sheela S. Small-incision cataract surgery in a case of cervicothoracic kyphosis: A surgical challenge. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Jul 3];58:119-21. Available from: http://www.tnoajosr.com/text.asp?2020/58/2/119/286933




  Introduction Top


A curved cervical spine accompanied by restricted neck extension of the patient is a challenge for an ophthalmic surgeon who needs the patient in a supine position. Usually, kyphosis is associated with systemic comorbidities, especially that of respiratory system. Hence, adopting uncommon positions for the patients such as Trendelenburg position may not be feasible. Here, we present a case which posed difficulties in positioning of the patient for cataract surgery.


  Case Report Top


A 60-year-old male, with severe kyphosis, presented to our clinic with defective vision in both eyes. Slit-lamp examination, performed with difficulty, revealed a mature cataract in the right eye and Grade IV nuclear sclerosis in the left eye with a vision of perception of light in his right eye and hand movements in the left eye. He had kyphosis since his birth, which severely limited his neck extension. He was unable to assume the usual supine position for lying flat on the bed. The patient did not find his kyphotic position as a hindrance to his activities of daily living and hence preferred not to seek orthopedic attention for the same. The patient was on systemic medications of tablet salbutamol 2 mg OD for his complaints of breathlessness as per physician's advice.

Our approach

Prior anesthetist, pulmonologist, and orthopedician fitness was obtained for performing cataract surgery under local anesthesia. Using several sheets of drapes, a large firm pillow was raised [Figure 1], which was positioned between the head of the bed and the patient's head, neck, and shoulders. It was aimed at relieving pressure on the lower spine, thereby making him more comfortable. The angulation between the horizontal and the axis of the neck of the patient was documented to be 60° [Figure 1]. The height of the operating surgeon was 179 cm (5 feet 9 inches). The surgeon's sitting position was elevated with the help of sand bags and sheets of drapes to attain the height required to reach the microscope [Figure 2]a. The operating microscope had to be fixed at maximum possible angulation allowed by the model [Figure 2]b to facilitate adequate field of view. Challenges faced when performing the surgery include difficulty in estimating the anterior chamber depth and necessity of constant traction on the globe toward the field of vision to keep the field of surgery under the microscope view. The entire procedure was completed in a time period of 15 min and 6 s.
Figure 1: Positioning of the patient on the operating table

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Figure 2: (a) Positioning of the operating surgeon on the raised seat, (b) maximum angulation of the operating microscope (top view)

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The limited field of view best appreciated from the video recorder attached to the microscope [Figure 3]. It required immense skill to be able to tackle the above-mentioned challenges and successfully implant the intraocular lens. Intraoperative period was uneventful. The patient reported no discomfort during or after the procedure. Postoperatively, the vision improved to 6/18 in the right eye on the 1st postoperative day[Figure 4] and the patient discharged. Small-incision cataract surgery was performed in the other eye as well in a similar fashion.
Figure 3: Limited field of view as seen on the video recorder

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Figure 4: Postoperative day 1 image of the right eye

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  Discussion Top


Hyperkyphosis (kyphosis) is excessive curvature of the thoracic spine, commonly known as the “dowager's hump.” Often being a congenital disease, it may also be caused by osteoporosis, degenerative arthritis of the spine, trauma, etc., This case report illustrates that it is possible to position patients with back and neck problems on a conventional operating table using a little ingenuity and with existing available resources. Both the patient's and surgeon's comfort are of utmost priority while surgery is being formed. If it is compromised, as in case of unconventional positioning of either the patient in the form of extreme Trendelenburg position to negotiate the kyphosis, sitting posture,[1] lying to one side,[2] or the operating surgeon having to stand throughout the surgery, the quality of the surgical outcome might be affected adversely. Cataract surgeries of many patients presenting at a relatively early stage are put off or delayed due to their arthritic conditions and their cataracts become unusually dense. Further inappropriate positioning of the patient might make the procedure a struggle and the risk for complications will be greater.

Several different approaches have been tried in individual situations to suit their specific challenge. Fine et al.[3] modified a standard waiting room chair to allow patients to be seated during surgery, but with their heads tilted back. This approach may work for patients with chronic obstructive lung disease, congestive heart failure, and esophageal reflux, but it may be impossible for patients with arthritic necks as in this case. Prasad et al.[4] solved the positioning problem for one of their patients using an orthopedic operating table, reclining it 60° from the horizontal which was difficult too with patient having respiratory difficulties. Livingston and Mackool[5] use a commercially available wedge-shaped pillow with a built-in donut for positioning the head that is suitable for patients with small amounts of cervical kyphosis. These authors recommend the simultaneous placement of a couple of pillows beneath the knees to relieve stress on the lower back.

Hence, an approach to lay the patient in the usual position and operate with the head more vertical than usual might be the last straw. A similar approach was suggested by Gordon et al.[6] Although this requires more skill and expertise, it ensures safety and comfort of the patient and avoids undue positive pressure associated with a head-low posture. With limited resource settings, where operating in a sitting posture may not be feasible,[7] this position allows for the relatively comfortable performing of the surgery for the surgeon, more so for the patient. Another approach of face-to-face phacoemulsification as suggested by Muraine et al.[7] would not have been possible in this case as it was hard mature cataract and due to unavailability of mobile slit lamp.


  Conclusion Top


While systemic and associated comorbidities continue to pose anatomic and physiological challenges to performing cataract surgery, it is crucial to devise methods and techniques to overcome the same with minimal utilization of resources. By simple repositioning of the patient in a particular way, using inexpensive aids, performing the surgery in the usual fashion is a better alternative to provide successful results to the patient.

Hence, it is essential to take these cases up a challenge to facilitate the restoration of the quality of patients' lives which has already been compromised due to the coexisting comorbidities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mark Packer MD. Video. Available from: http://www.surgytec.com/video/cataract-surgery-kyphotic-patient. [Last accessed on 2020 Feb 16].  Back to cited text no. 1
    
2.
Sambandam SP. Cataract extraction in a hunch back woman. Indian J Ophthalmol 1974;22:35.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Fine IH, Hoffman RS, Binstock S. Phacoemulsification performed in a modified waiting room chair. J Cataract Refract Surg 1996;22:1408-10.  Back to cited text no. 3
    
4.
Prasad S, Kamath GG, Phillips RP. Phacoemulsification in a patient with marked cervical kyphosis. J Cataract Refract Surg 2000;26:1258-60.  Back to cited text no. 4
    
5.
Livingston M, Mackool RJ. Donut wedge cataract positioner. Journal of Cataract and Refractive Surgery 1995;21:5-6.  Back to cited text no. 5
    
6.
Gordon MI, Rodríguez AA, Olson MD, Miller KM. Pillow case. Journal of Cataract & Refractive Surgery 2005;31:1824-5.  Back to cited text no. 6
    
7.
Muraine M, Boutillier G, Toubeau D, Gueudry J. Face-to-face phacoemulsification using a slitlamp in patients who are unable to lie flat. J Cataract Refract Surg 2019;45:1535-8.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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