kyphosis is a progressive curvature of the thoracic spine , which results in rounding or bowing of the back . a curved spine accompanied by restricted neck motion and poor lung reserve present challenges for an ophthalmic surgeon , who is used to patients neck and head resting flat on the operating table and the eye in the horizontal position . intraoperative difficulties include poor view , inability to maneuver surgical instruments properly and constant threat of elevated vitreous pressure . several innovative solutions have been published , including the maximal reverse trendelenburg position and pillows under the head and neck , use of a donut and wedge - shaped head positioner , allowing patients to remain in the upright sitting position while their head is positioned horizontally in a modified waiting room chair , performing surgery while standing [ 5 , 6 ] , using a 4-section orthopedic operating table , or laying the patients on their sides . however a 49-year - old obese male with controlled secondary glaucoma needed cataract surgery in the right eye . the past ocular history was positive for recurrent uveitis and glaucoma shunt surgery in the right eye . cataract density was + 4 , and the best - corrected visual acuity was 20/200 . the anterior chamber was shallow and the glaucoma shunt tube was visible at the 11 o'clock position . the patient was planned for pupillary dilation using iris retraction hooks , lens capsule staining with trypan blue and phacoemulsification with intraocular implantation under local anesthesia . the anesthesiologist was reluctant to use general anesthesia because of the patient 's disability and poor health . in the operating room , the patient could only recline to about 40 from the vertical axis despite maximal reverse trendelenburg position and a number of pillows under his back , neck , head and legs ( fig . 2 ) . while trying to focus the microscope , it became evident that by grasping the eye at the inferior limbus with a fine forceps and pulling it upwards , it could be moved to a more desirable horizontal position . a single 7/0 vicryl ( polyglactin ) corneal retraction suture was placed at the limbus at the 6 o'clock position to achieve the desired view ( fig . the assistant surgeon was able to rotate the eye to the desired positions during the whole procedure by relaxing or pulling the suture . patients with kyphosis may present several unique challenges to an eye surgeon , the foremost being the inability to lay the head and neck in the ideal horizontal position . the resulting poor view makes focusing and manipulation of tissues and instruments difficult . tilting the head end of the operating table down and raising the patient 's legs may compromise venous return from the orbit , causing venous engorgement and elevated posterior vitreous pressure during surgery . in addition , the patient 's poor pulmonary reserve itself may further impede orbital / jugular venous return , resulting in increased posterior vitreous pressure . other features of kyphosis that may adversely affect intraocular surgery are tenderness and stiffness of the back and difficulty in breathing . several practical solutions have been described by very experienced surgeons but complications may still occur . a wedge - shaped pillow with a built - in donut for the positioning of the head has been used by some surgeons . livingston and mackool   recommended using more than one of these positioners in severe cases . another approach suggested performing cataract surgery while standing , using loupes and making an inferotemporal scleral tunnel [ 5 , 6 ] . the surgeons were unable to remove the subincisional cortex because of a shallow anterior chamber secondary to elevated posterior vitreous pressure . prasad et al .   recommended using a 4-section orthopedic operating table to enable an extreme reverse trendelenburg position for cataract and glaucoma surgery . however , because of a blurred vision , these authors were unable to perform curvilinear capsulorhexis and had to resort to can - opener capsulotomy . in short , there is no single solution for the different groups of difficult patients . we have found that a single retraction suture at the inferior limbus can rotate the eye to any desired position . this may allow both the patient and surgeon to be in a comfortable position without compromising good view . it may be tried practically in all patients with kyphosis or other conditions that prevent them from reclining such as torticollis , chronic obstructive pulmonary disease , chronic congestive heart failure or morbid obesity . the surgeon can still sit on the preferred temporal side of the patient and perform intraocular surgery of choice . with this maneuver , it may be unnecessary to resort to extreme and uncomfortable tilting of the patient and avoid complications such as those described above . the authors have no financial or proprietary interest in the materials described in the article .
we describe a 49-year - old man with advanced kyphosis and dense cataract , who could only recline to about 40 from the vertical axis despite a maximal reverse trendelenburg position and pillows under the head , neck , shoulders and knees . with a single corneal retraction suture at 6 o'clock , the eye could be rotated horizontally , which enabled the surgeon to perform a complex cataract surgery despite prior glaucoma shunt , posterior synechiae , a small pupil and the need to stain the capsule . 
 as the eye can be brought into any desired position with a retraction suture , patients with kyphosis or other conditions that prevent them from assuming a supine position can still have safe intraocular procedures . 
 this maneuver reduces the need to tilt patients to an uncomfortable position that may cause pain , increased breathing difficulty and elevated posterior vitreous pressure .