As challenging cataract cases go, this one had it all. Mrs. V, a 5-foot-1, 341-pound, 67-year-old female with multiple co-morbid conditions, including hypertension, diabetes, obesity and sleep apnea, presented for surgery on her right eye. She uses nasal oxygen at 2 liters and ambulates with the aid of a walker, but with some difficulty. At bedtime, she needs at least two pillows and can't lie flat.

Because Mrs. V couldn't lie flat, we placed her on a battery-powered bed that can elevate and tilt in most any position. But this meant that we couldn't lower the table and allow the proper placement of the microscope — the working distance is 200mm — and that the surgeon had to stand during the case. Leg fatigue notwithstanding, "it would have been much more difficult with a typical stretcher," said Syd Tyson, MD. Our microscope has an adjustable binocular eyepiece, which is a huge asset for this type of visualization.

Pre-op assessment
Nurses interviewed Mrs. V in the pre-op area and inserted a 22g angiocath with a hep-lock to KVO in case we had to administer any medications or have emergency access. The anesthesiologist decided to have Mrs. V taken off of her portable oxygen unit and connected to the wall source once in the OR.

Mrs. V. stated that she also needs a rolled towel or blanket behind her neck for extra support. While still in the pre-op area, we rolled and placed a light blanket where it provided the most comfort in anticipation of her position in the OR.

We wheeled Mrs. V's reclinable chair into the OR, right up to the battery-powered bed, which was set in the sitting position. She was able to stand, with some assistance, and sit on the seat of the bed. We gave her a step stool to place her feet on so that she was able to push herself further back on the bed.

We applied the monitoring devices, NIBP cuff, EKG leads and O2 Sat monitors. As we slowly began to lower the back of the table, we intermittently and slowly raised the table's foot section with its back section. We raised Mrs. V's legs so that she wouldn't slip off the table, giving her a feeling of security in that she wouldn't fall. We placed the pre-made blanket roll behind her neck until she was comfortable.

As we slowly placed Mrs. V into a reclining position, the anesthesiologist began to administer a small dose of sedation to alleviate any anxiety.

When the table reached a semi-Fowler's position, the patient stated that she couldn't tolerate her head going further back. We then used the "back tilt," and the whole table tilted backward with the patient still in a semi-Fowler's position. We placed the table back to accommodate the procedure with her head level and her eyes parallel to the floor. This is necessary to let the surgeon see the red reflex and to help avoid any complications during the surgery.

Standing surgery
The final obstacle was the table height. With the patient not lying flat, we couldn't lower the table and allow the proper placement of the microscope.

Dr. Tyson stood at the temporal side of the patient. He asked the patient before the start of the surgery if she was comfortable. The patient responded "yes." He proceeded with the surgery. At this time the circulating nurse held the patient's hand. "That's just what I needed," said Mrs. V.

We adjusted the height of the BSS bottle as needed due to the elevation of the patient. We monitored the patient's vital signs throughout the procedure. The cataract was removed by phacoemusification and the IOL was implanted. The surgical time was six minutes with no complications.

A patient who clearly was a challenge for routine cataract surgery ultimately ended up with a good surgical result. The early recognition and intervention of these problems by the surgeon and the rest of the surgical team let this patient have the surgery with no complications or untoward effects.