Sir,

While vitrectomy is typically performed with the patient supine, technical difficulties arise in patients who are unable to lie flat. Modified equipment and patient positioning have been described for cataract surgery.1, 2 However, no position modifications have been described for vitreoretinal surgery. We report a positioning and surgical technique for pars plana vitrectomy in a severely kyphotic patient.

Case report

A 65-year-old male with severe kyphosis and prior cervical vertebral fusion with limited neck extension presented with retained lens fragments after cataract surgery and medically uncontrolled intraocular pressure in the left eye. Ability to position supine was tested in an examination chair (Figures 1a and b). Intra-operatively, the gurney was tilted to a Trendelenburg position (25–45°, head down). The patient’s neck and shoulders were supported with foam pillows and towels that were taped, and the patient’s thighs were supported by pillows. The surgical belt was tightened. A stool was placed under the head of the bed for support, in the event of bed breakage from extreme positioning (Figure 1c). The operating microscope with wide-angle viewing system (OPMI LUMERA 700 and RESIGHT, Carl Zeiss Meditec, Jena, Germany) was rotated 20° to align with the corneal plane. A temporal surgical approach was used (Figure 1d). Intraocular pressures were 20.5 mm Hg in the right eye and 19.5 mm Hg in the left eye, measured by a pneumatonometer. A mild intravenous anesthetic was administered, followed by sub-Tenon’s anesthesia. Three-port 20-gauge pars plana vitrectomy and lensectomy were performed. Infusion pressures were kept low (10–20 mm Hg). Postoperative results were favorable, with no increase in neck pain.

Figure 1
figure 1

(a) Photograph of the patient standing upright in the clinic, demonstrating kyphosis. (b) Prior to surgery, the patient was reclined in an office examination chair in order to determine his head position while supine. (c) At surgery, the patient was placed in Trendelenburg position with towels under his head for extra support, along with a stool placed under the operating table for added stability and safety. (d) Temporal approach vitrectomy and lensectomy were performed with the patient in Trendelenburg position.

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Comment

Trendelenburg positioning and temporal approach can be used for vitrectomy in patients who cannot lie flat. In some cases a superior approach may be feasible, depending upon the surgeon’s access to the eye over the brow. Trendelenburg positioning can cause cardiac and pulmonary stress, increase intraocular pressure by 10–20 mm Hg3 and decrease cerebral perfusion and ocular perfusion pressure.4, 5 Infusion pressures should be kept low and operating times minimized to prevent these sequelae. An in-office trial of Trendelenburg positioning can simulate the operating table. Careful review of the patient’s ocular and medical history and planning with a multidisciplinary team can help achieve surgical goals while maximizing patient comfort and safety.