Sir,

I was interested to see Nair and Rimmer's report of ‘side-saddle’ positioning for phacoemulsification in patients who are unable to lie flat.1 I have been using a virtually identical technique for the last 2 to 3 years,2, and I suggest some refinements. Topical-intracameral anaesthesia allows the patient to fixate the operating light and therefore keep the eye still, in the desired position, with a good red-reflex. Surgery may be further facilitated by a face turn, and/or chin-up head positioning, if the patient is able to do this. With these adjustments, it is usually easy to make an on-axis incision, which may be inferior, temporal, or nasal, as required. Sometimes it is more comfortable for the surgeon to stand rather than to sit, facing the patient. The more upright the patient, the more the operating microscope must be turned towards the horizontal, and consequently the surgeon's arms will be more outstretched. With more extreme positioning, the outstretched arms can make surgery feel less controlled than normal: in these cases, I prefer to use a ‘divide and conquer’ technique with a straight second instrument, rather than risk iris trauma with an angled chopper. My personal practice is to use the ‘standing-temporal approach’3 for most patients who cannot lie flat, and to reserve ‘side-saddle’ positioning for those who cannot adopt the required ‘face to ceiling’ position, or who need an inferior incision for astigmatism.

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