Cataract Surgery in Patients Unable to Lie Flat: A Systematic Review and Surgical Decision-Making Framework

Purpose: To systematically review all described approaches to cataract surgery in patients unable to lie supine and propose a clinical decision-making framework. Clinical Relevance: Conditions precluding supine positioning include kyphosis, orthopnoea, and morbid obesity, which affect a substantial and growing proportion of patients requiring cataract surgery. No standardised guidance exists to direct surgical management in this population, representing a meaningful gap given that cataract surgery is the most cost-effective operation in medicine. Methods: This systematic review underwent prospective PROSPERO registration (CRD420261288661). In accordance with PRISMA 2020 guidelines, we systematically searched and appraised all described approaches to completed cataract surgery in patients unable to recline for any reason across PubMed, Scopus, and EMBase on August 25th, 2025. Data were extracted regarding technique, equipment required, ergonomic considerations for surgeon and patient, and secondary outcomes including complications or position-specific challenges. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale for case-control and cohort studies, and the Murad Tool for case series and case reports. Results: Twenty-five studies were included, demonstrating three dominant approaches that have been utilized to perform cataract surgery in patients unable to lie supine: special positioning to facilitate a semi-recumbent position, surgery carried out with the surgeon standing, and positioning so that the surgeon and patient are face-to-face during surgery. There are only a few instances where conventional phacoemulsification has been performed under slit lamp microscopy in seated patients, presenting only limited data evaluating the safety of this practice. Conclusions: There are three distinct categories of approaching cataract surgery on patients unable to recline, which although still technically challenging, can increase the number of patients eligible to undergo cataract surgery in both developed and developing countries. We present a clinical decision framework proposed to guide approach selection based on mechanism of positional limitation, equipment availability, and case complexity.