Modifications in cataract surgery for the morbidly obese patient Ahmad M. Mansour, MD, Mays Al-Dairy, MD We describe a standing phacoemulsification technique (SPT) with the patient in re- verse Trendelenburg position (RTP) as a means of performing surgery in morbidly obese patients. These patients have elevated vitreous pressure, leading to a high rate of posterior capsule rupture and vitreous loss. The SPT with RTP normalizes vitreous pressure, facilitating cataract surgery. J Cataract Refract Surg 2004; 30:2265–2268  2004 ASCRS and ESCRS S edentary lifestyles combined with food-industry Results changes have contributed to an epidemic of obesity. A retrospective chart review of patients with morbid With a growing percentage of the world becoming mor- obesity who had phacoemulsification was performed in bidly obese (body mass index [BMI] greater than a private clinic setting covering 10 years (July 1993 to 39 kg/m 2 ), physicians may need treatment plans to June 2003). Surgery was performed in 9 of the patients address special issues with these patients: comorbidities, by 1 surgeon (A.M.M.). transportation, intravenous access, anesthesia problems, Of 9 eyes in 7 patients in whom phacoemulsifica- wound dehiscence, and postoperative care. To our tion was performed in the supine position, 2 eyes of 2 knowledge, complications of cataract surgery related to patients (22%) had a posterior capsule rupture. In the morbid obesity have not been discussed in the literature. first eye, anterior vitrectomy was performed in the same setting. In the second eye, pars plana vitrectomy and Surgical Technique removal of the residual outer nuclear sheet were per- The standing phacoemulsification technique (SPT), formed in a separate surgery. Four eyes in 3 patients shown in Figure 1, has the following characteristics: had phacoemulsification in RTP, and none had positive The surgeon is standing. The surgical microscope is at vitreous pressure or intraoperative complications. A minimum magnification and is in the maximum upward problem noted in most cases was forward and backward position. The patient is positioned in a reverse Tren- movement of the eye with each respiration. This techni- delenburg position (RTP) to fit the focus of the micro- cal difficulty was partially overcome by low magnifica- scope. A 1-handed and 1-legged phacoemulsification technique is used (1 leg for support, 1 leg for the tion of the surgical microscope and by placing the phacoemulsification pedal). A superior limbal approach surgeon’s wrist on the patient’s forehead. is taken. Discussion Accepted for publication February 24, 2004. Patients with morbid obesity are at an increased From the Department of Ophthalmology, American University of Bei- risk for cataract 1–3 and elevated intraocular pressure rut, Beirut, Lebanon. (IOP). 4 The cardiopulmonary and ocular changes with Neither author has a financial or proprietary interest in any material morbid obesity are presented in the operating room. or method mentioned. The BMI is an important determinant of lung vol- Reprint requests to A. Mansour, MD, American University of Beirut- ume, respiratory mechanics, and oxygenation during Ophthalmology, PO Box 113-6044, Beirut, Lebanon. E-mail: dr. ahmad@cyberia.net.lb. general anesthesia with patients in the supine position.  2004 ASCRS and ESCRS 0886-3350/04/$–see front matter Published by Elsevier Inc. doi:10.1016/j.jcrs.2004.02.088