Healthy, Efficient Body and Hand Positions for Cataract Surgery

Notes About Body Positions

Body and hand positioning is absolutely essential to cataract surgery and maybe the most important part. Without correct body position and hand position, it will be very hard to get the instruments stable and in the locations in the eye that you desire.

Body positioning at the microscope.

This is one of the most important steps of cataract surgery. Keep elbows and arms down at your sides. This allows for relaxed shoulders and arms that in turn allow cataract surgery to be done with the delicate, fine-tuned muscles of the fingers instead of the coarsely tuned arm and shoulder muscles. It also will allow for greater comfort, headache and stress prevention and career longevity through prevention of chronic neck conditions. Note also that the wrists are in a neutral position. We will deal more with wrist and hand position in other graphics. Notice that the feet are both slightly forward from the surgeon and in a natural position on the pedals. This is achieved by having the chair at the right height for the feet to rest on the pedals and for the legs to fit under the patient’s bed. The back and neck are straight and neither in flexion nor compression. All of the body is aligned and in a natural position. Achieving this position quickly will improve efficiency. When I work with residents, the resident may spend as much time achieving a good position as it takes me to complete a whole case. Do not get discouraged, keep practicing this correct positioning as it is the baseline for other skills. Practice and repetition of good habits as well as establishing key markers, such as the bar on the bed should hit just above my patella when it is the right height for me, will make good positioning efficient and repeatable. Keep in mind that there may be patients for whom good positioning is impossible – I once had a patient so kyphotic that I had to do the surgery standing up. These situations are part of being a surgeon, but should be minimized for efficiency, patient safety, and surgeon longevity.

Notes About Hand Positions

Instrument position in the hand may be the single most important thing in achieving good cataract surgery. If one were to look at great surgeons around the world, there is considerable variance in how people hold instruments, but the technique shown here has been used by some of the best ever and makes sense from the standpoint of physics and physiology. The major proponents of these hand positions are Alan Crandall and Ike Ahmed, both among the greatest surgeons I have ever seen and mentors of mine.

Hand Position Specifics

The left hand sits on the ring finger, pinkie, and soft part of the hand covering the 5th metacarpal and hypothenar eminence. This forms a stable platform from which all instrument movement can be accomplished with the fingers. This platform should be so stable that your attention can be turned away from your left hand for a period of time and when it returns, your instrument will be in the same position. It also is essential that this instrument does not lift or depress the eye and the paracentesis wound leading to egress of fluid and an unstable chamber. The right hand wrist turns parallel to the floor allowing the instrument to enter the eye at a low angle. The instrument is grasped by the thumb, index, and middle fingers. The ring and pinkie fingers are held stable on the patients face and the wrist and elbow are kept low. This instrument should be moved almost exclusively into and out of the eye with the action of the fingers only. Think about holding a dart, not a pencil.

Instrument Handling

1. Second Instrument: non-dominant hand

2. Phacoemulsification handpiece: dominant hand

1. The instruments in the left hand can be moved in multiple axes (see below left). I recommend minimizing movement in the Y and Z axis and concentrating only on the x axis and rotary movement around the x-axis and in the x-y rotational axis. Rotations on the YZ axis can be used to rotate a sharp tip of a vertical chopper away from the capsular bag when removing the last quadrant of the nucleus. Movements in the Y and Z axes result in movement of the eye in the field of view and also will usually result in gaping of the wound, chamber instability, and corneal striae reducing visualization in the anterior chamber. By having the left (or non-dominant hand) stably positioned on the patients forehead or cheek, the fingers can be used to generate all of the necessary movements without movement of the hand or arm leading to great stability and positioning of the second instrument.

2. The phacoemulsification handpiece, like the second instrument can be moved in the x, y, and z axes as well as rotational axes as well (see below right). In general, the phaco should only be moved along the Y-axis, or into and out of the eye, and rotationally around the Y-axis. Any other kind of movement with the phacoemulsification handpiece will move the eye, gape the wound, decrease chamber stability and bring the phaco tip near structures like the iris, endothelium, and capsular bag that should be protected. Especially common is to rotate on the YZ axis of movement and lift the back end of the phaco pushing the eye into the nose and gaping the main wound. “Drop your hands,” was the most common single comment Alan Crandall had while teaching me. Dropping the wrist and shoulders back into a neutral position will flatten the phaco handpiece back into the correct position.

Helpful Videos and Links For Topics Above

Instrument Handling:

Cataract Surgery Shown with Hand Positions:

Quiz yourself: https://forms.gle/pATzsnzs8gzmfLAA8

Counseling Patients

Pre-Operative Examination

Intraocular Lenses

Anesthesia

Types of Anesthesia

Topical with MAC: This usually uses tetracaine on the surface and lidocaine with or without epinephrine intracamerally. Anesthesiologist may consider giving versed, diazepam, fentanyl, propofol or other anesthetics intravenously, but these are not required for patients as the tetracaine and intracameral preservative-free lidocaine will be adequate for ocular pain control.

Retrobulbar Block (RBB): Use a blunt Atkinson retrobulbar needle when possible. There are variations on how to do this depending on the amount of anesthesia, akinesia, subconjunctival edema, and posterior pressure one is willing to accept during the eye during surgery. In general with my blocks, I use a technique that maximizes anesthesia and akinesia by injecting into the subtenon’s portion of the muscle cone. When done correctly this will result in complete anesthesia and akinesia. It may also result in some subconjunctival edema and mild posterior pressure. The posterior pressure can be relieved with a Honan’s balloon or other methods of providing gentle posterior pressure to the globe. The most common error in doing the retrobulbar block is to not change the angle enough to get into the muscle cone and instead remaining on the orbital floor. This will result in inadequate anesthesia and akinesia. Use care in changing angle to avoid putting the needle through the glove or into the optic nerve. Check to be sure you are not in a blood vessel prior to injection. I usually use about 4 cc of half 2% marcaine, half 0.75% bupivicaine with 150 mcg of hyluronidase.

Peribulbar block: This procedure is similar to a retrobulbar block, but accesses the muscle cone using a subtenon’s injection. My technique involves making an incision through conjunctiva and tenon’s down to bare sclera in the inferotemporal quadrant (this quadrant has no extraocular muscles). Once bare sclera is reached a Wescott scissors is used to blunt dissect into the subtenon’s space posterior to the globe. The block (half Marcaine and half bupivacaine) is then injected into this space on a large cannula such as a Bishop-Harmon 19g BSS cannula.  

Helpful Videos and Links for Topic Above

Quiz yourself: https://forms.gle/nSUc7iLYrxRqvyPS9

Patient Positioning

Prepping and Draping

Notes about Prepping and Draping

There are a lot of different kinds of drapes and just as many opinions about which is best. I prefer drapes that can easily be placed without touching the skin of the face. I also prefer not to use a wrist rest as it can prevent proper hand position if it is too high.

Prep should be performed with betadine 5% into the eye. The skin around the eye may be prepped with 5% betadine or 10% betadine. In patients with clinically significant betadine allergy, there are other preps such as PCMX (3% para-chloro-meta-xylenol) or BAK (benzalkonium chloride). True allergies to betadine are rare (contact dermatitis in response to betadine is not a true allergy according to the American Academy of Allergy, Asthma and Immunology). A lot of different drapes and draping styles exist, but a couple principles apply to all methods.

Principles of Prepping and Draping

When draping, use caution to not touch the skin around the eye with your gloves. The drap should isolate the eye from the nose and other skin around the eye. The lashes should be draped out of the field. It is believed that most infection comes from the lashes, and the lashes also decrease visibility during surgery if they are in the surgical field. The lid speculum should be placed in a way as to provide adequate exposure, but not so aggressively as to cause damage to the eyelids or the eyelid muscles. It is possible to cause ptosis or other damage to the lids with the eyelid speculum. For this reason I prefer to use speculums that are adjustable such as the Leiberman or Cionni speculum where the opening width of the palpebral fissure can be controlled as opposed to a spring loaded speculum.

Helpful Videos and Links For Topics Above

Prepping and Draping: https://www.youtube.com/watch?v=ji94fgulUKA (get a different video)

Quiz Yourself: https://forms.gle/FKvkJmHn4y7URnTf8