Cataract surgery in difficult patients

by Joseph San Laureano | Nov 21, 2013 | blog

I am often asked wether it is possible to perform cataract surgery on patients with deformities such as kyphosis or other back condition that prevents them from lying flat. The answer is generally a qualified ‘yes’.
There is no doubt that surgery in these patients is difficult for both surgeon and patient. Complications are more likely to occur if there is poor visualization, if the patient is constantly moving or is confused or if there is poor access such as a prominent brow, deep set eye or small eye.

The patient with back problems is not generally much of a problem as we have quite sophisticated theatre tables that can be set in virtually any position. The patient pictured above is a good example of this. This was a woman who had quite severe kyphosis and was permanently hunched. The theatre table that we used was able to cope to and extent but we also required to pack numerous foam blocks under her head. The table was tilted to allow the face to be horizontal with her body ‘up in the air’.

The more challenging patient, is the moving one. Occasional, patients with early dementia, become disoriented particularly when any sedation is used. They may not be aware that there are having surgery and can become distressed and almost impossible to operate on. Further attempts at sedation often results in more confusion and agitation. In these cases, a general anaesthetic may be required. The moving patient is no doubt one of the most difficult to deal with. For Surgeons accustomed to operating under topical anaesthesia, this is not as disconcerting as it would be for a surgeon who regularly performs surgery under a regional block. Most eye surgeons, particularly the older ones tend to still perform surgery under a block.

The patients with small pupils, dense white cataracts or opaque corneas are also difficult. The introduction of Trypan blue has made surgery in these patients much easier. Trypan blue was introduced by Prof Minas Coroneo in Sydney and is essentially a blue dye which stains the anterior capsule and allows better visualisation. Thus an opaque cornea becomes less of a challenge as the contrast between lens and capsule is better seen through the ‘fog’. Similarly, performing a capsulorhexis is made easier if there is contrast between the white lens and the blue capsule.

Small pupils, and floppy irises are another challenge. Patients who have been on long term eye medications, have pseudoexfoliation (PXF) syndrome or just plain don’t dilate can usually be managed with either iris hooks or a pupil stretch. More recently, Boris Malyugin, a Russian eye surgeon has introduced the ‘Malyugin’ ring which opens the small pupil with much less effort than before. Similarly, the patient on Alpha agonists such a Flomaxtra for bladder control end up with a floppy iris which is more likely to prolapse during surgery. Here again the use of a Malyugan ring has been transformative, converting a nightmare procedure into a straight forward one.

Malyugan Ring

Many non eye surgeons often comment to me that eye surgery is easy. My response is to say that to a skilled pilot, flying is easy and to a skilled neurosurgeon, neurosurgery is easy. Cataract surgery in experienced hands is often easy but there are many situations in which it is far from easy and can be fraught with complications.