Sir,

Patients who cannot lie flat for cataract surgery pose a challenge if general anaesthesia is too risky. The surgeon is obliged to stand,1, 2, 3 and bearing weight on one leg to operate the foot pedals is uncomfortable.

Study of the history of cataract extraction, as opposed to couching, shows that the first patients were sat upright during the procedure where, in 1753, Daviel used an inferior section.4 His own operating position, with legs either side of the patient's (Figure 1a, http://www.escrs.org/Publications/Eurotimes/04October/pdf/ESCRSParisCongress.pdf), would not suit modern theatre furniture but does prompt a rethink for this difficult group of patients. We suggest an alternative posture for the surgeon, which is not a big change for surgeons familiar with operating from the side.

Figure 1
figure 1

(a) Posture used by Daviel in 1753. (b) A patient unable to lie flat is positioned for cataract surgery. (c) The povidone iodine now tracks towards the patient's collar, which is protected by absorbent material. (d) With the axis of the microscope tilted back 60° from the vertical, and the foot pedals parallel to the long axis of the operating table, the surgeon is able to position himself comfortably.

Full size image

The patient is positioned with the head rotated towards the surgeon and the foot pedals are placed parallel to the long axis of the operating table (Figure 1b). Written permission was obtained from these patients for publication. Absorbent material is tucked into the patient's collar to protect it from the povidone iodine, which now tracks down the neck instead of towards the ear (Figure 1c). The surgeon uses an infero-temporal approach, but sits side saddle, with his thighs parallel to the long axis of the operating table and facing the head end (Figure 1d). The optical axis of the microscope is inclined about 60° towards the horizontal, and the globe is tilted a little more superotemporally than usual to optimize the red reflex if present.

We have used this positioning for about 10 patients now. All patients had intracameral anaesthesia and some required capsular staining and pupil stretching. All but one had uneventful surgery. One patient needed anterior vitrectomy, which was not significantly more difficult than usual. We would not expect the risk of endophthalmitis to be any different from that of a temporal section. Although the surgeon had to take the weight of his arms a little more than usual, he found this posture to be far superior to the alternative of standing.