Commentary: Lying down looking down test: Evaluating patient suitability for small incision cataract surgery using assisted topical anesthesia

Purpose: The objective of this study was to evaluate an OPD-based Lying down looking down (LDLD) test for the assessment of patient suitability for assisted topical anesthesia (ATA) during manual small incision cataract surgery (MSICS), and to compare it with assisted local anesthesia (ALA). Methods: The LDLD test was carried out during preoperative assessment of 250 consecutive patients. A standard LED torch was shined in patient's eye after pupil dilation, with the patient in lying down position, while simultaneously elevating the upper eyelid digitally. A positive test was indicated by the ability to maintain downward gaze and the lack of squeezing of eyes or withdrawal. Chi-square and Fisher's exact tests were used to assess the association between LDLD results and suitability for ATA. The positive predictive value and specificity of the test as an indicator of patient suitability for ATA were calculated. Complications (intra- and post-operative) and postoperative inflammation at day 1 and week 6 were compared between the ATA and ALA groups. Results: A total of 250 patients were included in the study, 138 in ALA group and 112 in ATA group. There were 109 males (43.6%) and 141 females (56.4%). Around 7.4% of LDLD- positive patients were converted to ALA during the surgery. Chi-square and Fisher's exact tests demonstrated a significant association of a positive LDLD test with successful ATA (P value 0.002). The positive predictive value and specificity of the test were 92.56% (95% CI86.87-95.9%) and 93.48% (95% CI87.98-96.97%), respectively. Intraoperative complications were similar in both the groups. Congestion and visually significant corneal edema were significantly less in ATA group. Conclusion: The LDLD is a simple, highly specific, OPD-based test to determine patient suitability for MSICS under ATA