Today, we're going to be talking about optimal positioning for cataract surgery. Positioning of the patient is the first step of cataract surgery, and one of the most important. A poorly placed patient will affect subsequent steps of the surgery. So it's important we have the patient in the right position. First step, when the patient comes in the room, they're usually sitting upright, like this. What we need to first do is flatten the bed, and then get the head in the right position, which I'll do now. [SOUND]. Once the bed is flat, I move to the head of the bed, and ask the patient to lift their head. Remove the pillow and place it down near their feet. If you rest your head back, we can see that there's a gap here between the top of patient's head, and the top of the headrest. We need to close that gap. What I'm going to have you do, is move up toward the top of the bed. If you bend your knees and push, scoot up to the top, that's perfect. Now the crown of the head is even with the top of the bed and we're in good position. The next thing I want to look at though, is how is the position of the head. And as you can see here, the brow is actually lower than the cheek. The head is actually kind of tilted back like this. That's not ideal for surgery. What we want to do, is have a line between the brow and the cheek be basically parallel with the ground, so that we have a nice even surface for surgery. Fortunately, this head rest is adjustable. I just lifted the head slightly. And now, when I readdress the orbit, we can see that everything is perfectly parallel to the ground. This is great. Now that we have the patient flat on the bed and in great position for surgery, we want to ensure that this stays this way for the entirety of our operation. So, what we need to do is secure the patient. What I'm first going to do is turn my attention to the head of the patient, and a personal choice I do, is I like to tape the head of the patient. What I'm going to do here, is grab a roll of medical tape, and I'm going to move to the patient's head. Since, in this particular case I'm operating from the right side, what I like to do is just rotate the head about five, or ten degrees to the right, so that when I'm operating temporally, if my hands are pressing on the face, and it pushes it slightly away, I haven't pushed the patient's head away from me completely. So, to adjust for that, we have the five to ten-degree angle towards me, when I tape the head. [SOUND] What I'm going to be doing here is putting a little tape around your head, just to secure it in place. >> Okay. [SOUND]. >> I usually go twice around, and just enough pressure so it holds still. But we obviously don't want it to be uncomfortable for the patient. That's great. For the next step, we don't want the patient to help us, meaning we don't want them to put their arms up, and start to touch their eyes during the surgery. So we like to secure the arms as well. What I'm going to do here, is wrap the patients arms inside the sheet, or what we call a papoose, and we'll clip them into place. This is just going to make sure that you don't help me during the surgery. For the last step, what I like to do is take pressure off the lower back, so that the patient doesn't become uncomfortable. To do that, we have the pillow that was initially with the patient when they came in the room. And we'll conveniently place that under her knees. If you lift your legs up slightly, I'm going to slide this pillow underneath. Great. You can rest your legs down. How does that feel? >> Feels wonderful. >> Great. I've already shown you an optimal situation where we're able to lie the patient flat, and have the head be flat, and parallel to the floor. However, our patients come in all different shapes and sizes, and we're going to talk about a couple scenarios where we don't have the ability to have the patient lie completely flat. In this situation, the patient, let's say, has severe Kyphosis, and the neck is in a severe angle of flexion. In this scenario, it'd be very difficult, because the patient is unable to get their head to go any flatter, and us trying to do that will just result in pain. So what we need to do is make some adjustments, because obviously sitting here, this would be very difficult to perform cataract surgery with the head at this angle. One thing we can do, is take advantage of the bed and actually adjust the position of the bed, and put it into a Trendelenburg position with the feet being higher than the head. Just adjusting the angle of the bed, will account for the majority if not all of the neck flexion. Let's demonstrate. [SOUND] I'm going to raise the bed, because I'm going to be lowering the head. Sometimes we need to raise and lower several times to get exactly the angle we like. But as we do that, you can see that overall, the head is now much more even than it was at the beginning. We're still at a slight downward angle, but this is much more advantageous for doing surgery, and I'd be ready to proceed just like this. In this particular scenario, we have a patient who has COPD, and lying flat is just not possible. It creates shortness of breath and a severe cough, neither of which we want during surgery. However, this patient has told me that she's actually able to do okay, if we're able to keep her somewhat elevated. So let's try and do that with the bed, and then adjust the position of the head to account for that. I'm going to raise the bed, and then go into reverse Trendelenburg, with the feet down. [SOUND] Is that easier for you to breathe? >> Yes, it is. >> It's easier for her to breathe like this. But unfortunately, we have a little bit of a downward angle on the head. So, because she doesn't have any neck problems, I'm just going to adjust the headrest somewhat, and account for that. I'm going to be lowering your head here. [SOUND]. Is that still comfortable for you? >> Yes. >> Still able to breathe, head is now in a better position for surgery, we're ready to proceed. Now that we have the patient all positioned well, and we have the drapes on. We want to make sure the patient's still comfortable. As you might imagine having a, a dark drape over your face might cause some anxiety, and for other people with severe claustrophobia, it can actually induce some panic. There's a couple things we can do. One thing I like to do is use the case from of our packets from the Phaco machine, and actually place this under the drape. It creates a little bit of a tent. I'm going to slide this box under here. It'll form a little tent for the oxygen to flow in. How does that feel? >> That feels good. >> Most of the patient's do well with just this small step. However, there are a few who really get claustrophobic when we do a couple extra steps. Number one, we can always ask for anesthesia colleagues to give a little bit more sedation to relax the patient. But, the other thing we can do is actually pin up the drape. Let me show how that works. I've got an IV pole here, and as I bring it in, again one of our clips, I just grab the edge of the ophthalmic drape, pull it up high on the pole, and clamp it into place. This creates a little pathway for the patient to see out with their other eye, and allows the patient to feel less claustrophobic. Is that better under there? >> Yes it is. >> Great. I'm now going to demonstrate the use of the wrist rest. The wrist rest is common attachment to the surgical bed, and it allows the surgeon to have platform for the wrist, or their hands during the cataract surgery. There's a portion of the wrist rest that translates inside of the bed near the head rest. There's two adjustments. One is to tighten that once it's inside the head rest. And number two, is a second adjustment for the height of the wrist rest. We'll want to make sure that both of these knobs are tight once we introduce this. This also is on a hinge, so that it allows us to slide it in without interfering with the patient's head initially, and then put it down into place. Let me demonstrate. What I'm going to do, is find the whole at the top of the headrest. Slide it in. And then gently tighten the knob. And as I flip it over, I want to make sure obviously it doesn't hit the patient's head. And what I like to do, is leave a gap approximately the width of a finger, between the wrist rest and the patient's head. And, we'll slide it up to the appropriate height, and then tighten it into place. If I'm sitting then in my chair, I can rest my wrist right on this wrist rest and have a nice stable platform for surgery. The advantage of this is, it's sort of like training wheels for a bike. It's an extra safety step. Something that you can feel secure about having your hands and wrists on. The downside is, if the patient where to move their head during surgery, my hands don't necessarily move along with that. So I think personally, there might be a little slighter chance of a complication with a big head movement. So for me personally I like to rest my hands on the patient's face. It allows my hands to move if the patient head moves. But it is an option for you during surgery. Now, that we have the patient positioned properly. They're prepped, they're draped, they're ready to go. We can't forget about ourselves. Unfortunately, cataract surgeons have a lot of problems with neck, and back issues due to poor posture during surgery. Even though it's a short operation, many of us do many during a particular day, and poor posture will add up. So let's be consistent with good posture, and I'll demonstrate here. First I'm going to pull up the chair, and bring myself closer to the patient. And what I want to do, is first check the position of my legs. Right now I'm not at a 90 degree angle with my knee, I'm actually sitting up too high. That would result in me kind of needing to bend over to work on the patient. So, the first thing I'm going to do is lower my chair. Now that I've lowered my chair, my knee is still bent at a 90 degree angle, and I'm able to comfortably approach the patient. The next things I want to check are my elbows. So, again, my arms I want to be at a 90-degree angle. And have my hands rest comfortably on the patient's face. This is great. The next thing I'm going to do, is make sure that neck, and my shoulders are also in a good upright position. When I bring the microscope into the patient's view, and my neck is comfortable. Right now you can see the oculars are below my eyes. When the ocular is below my eyes, I can either hunch down, and lose my good posture, or I can adjust the oculars. If I raise the oculars, I'm able to maintain great posture, still be in great position to do the surgery, and yet minimize the chances of me developing problems later. This is the way to go. We're going to have a little discussion about choosing anesthesia when it comes to cataract surgery. Patients come from a wide range of backgrounds in terms of their health status, and surgeons have a wide range of experience. And there's several different options that we can choose when performing cataract surgery, in terms of providing their anaesthesia. In the simplest form, we can provide just topical anaesthesia with eye drops and verbal encouragement to the patient during the surgery, and often get them through a relatively short procedure just fine. Other times, the patient may require more of a local anaesthesia, such as a retrobulbar block. Or, in most extreme cases, may even require general anesthesia. And there's various factors that we consider when deciding what type of anaesthesia to choose for each patient. The most important thing I can tell you today, is have a discussion with the anaesthesiology, before cataract surgery, if there's any question at all about what the most appropriate anaesthesia is for your patient. A discussion before surgery is so much better than having something unplanned happen during the middle of an operation. It reduces everyone's stress considerably to have good communication beforehand. Now when it comes to an individual patient we look at various factors. For one, how severe is their health condition. Are they even able to tolerate general anaesthesia or will that put them at a significant cardiac or pulmonary risk. For a local anesthesia injection, some patients are not good candidates for that because of the structure of their eye. So we have to think about structure of the eye as well, in addition to their general health status. The third thing that we want to consider is, what's your own level of experience? If you've not done a lot of cataract surgery, you certainly want to be more conservative with your anaesthesia choice, than if you are a more seasoned surgeon, which you can more comfortably do the surgery under topical anaesthesia. The most important thing, other than discussing things with the anaesthesiologist, is to remember this. The patient's health comes first, then the patient's vision, then your own comfort level. Granted we would all love to do cataract surgery under general anaesthesia for every single patient, but not only is that not feasible, but it's not safe for the patients either. Come to a good decision, and then stick with your plan, but don't be afraid to adjust if something changes during the surgery.
