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pain and discomfort. In summary, if a 23-gauge trocarcannula kit is readily available in the operating room,it would be easy to use in glued IOL implantation bythe anterior segment surgeon.

REFERENCES1. Hubschman JP, Gonzales CR, Bourla DH, Gupta A, Schwartz SD.

Combined 25- and 23-gauge surgery: a new sutureless vitrectomy

technique. Ophthalmic Surg Lasers Imaging 2007; 38:345–348

2. MentensR,Stalmans P.Comparisonofpostoperativecomfort in20

gauge versus 23 gauge pars plana vitrectomy. Bull Soc Belge Oph-

talmol 2009; 311:5–10. Available at http://www.ophthalmologia.

be/download.php?dof_idZ616. Accessed January 1, 2010

3. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S.

Fibrin glue–assisted sutureless posterior chamber intraocular

lens implantation in eyes with deficient posterior capsules. J Cat-

aract Refract Surg 2008; 34:1433–1438

4. Prakash G, Jacob S, Kumar DA, Narsimhan S, Agarwal A,

Agarwal A. Femtosecond-assisted keratoplasty with fibrin glue–

assisted sutureless posterior chamber lens implantation: new tri-

ple procedure. J Cataract Refract Surg 2009; 35:973–979

5. Nair V, Kumar DA, Prakash G, Jacob S, Agarwal A, Agarwal A.

Bilateral spontaneous in-the-bag anterior subluxation of PCIOL

managed with glued IOL technique: a case report. Eye Contact

Lens 2009; 35:215–217

6. Prakash G, Ashokumar D, Jacob S, Kumara KS, Agarwal A,

Agarwal A. Anterior segment optical coherence tomography–

aided diagnosis and primary posterior chamber intraocular lens

implantation with fibrin glue in traumatic phacocele with scleral

perforation. J Cataract Refract Surg 2009; 35:782–784

7. Chawla HB, Adams AD. Use of the anterior chamber maintainer

in anterior segment surgery. J Cataract Refract Surg 1996; 22:

172–177

Phacoemulsification surgery in 105-year-oldpatients

Wensheng Li, MD, PhD, Gang Sun, MD,Qinxiang Zheng, MD, Ronghan Wu, MD, PhD

Cataract is the most prevalent eye disease in theelderly and is a leading cause of vision loss in the devel-oping and developed worlds.1 Cataract extraction isone of themost commonprocedures performedworld-wide. Surgical removal of cataract in a 105-year-oldpatient presents special challenges to the surgeon.

CASE REPORTS

Case 1

A 105-year-old man presented to us in June 2005with complaints of decreased vision in both eyes formore than 20 years and loss of vision in both eyesover the previous 3 months. Examination revealed vi-sual acuity of 0.02 in the right eye and counting fingersin the left eye. Both eyes had accurate light perceptionin every direction. The intraocular pressure (IOP) was10.2mmHg in the right eye and 9.8mmHg in the left eye

J CATARACT REFRACT SURG

and the corneal endothelial cell count, 3154 cells/mm2

and 2544 cells/mm2, respectively. Both eyes showednearly mature cataract and lack of red fundus reflex.The chest X-ray and ultrasound scan of the abdomenand heart showed no abnormalities.

Topical anesthesia using proparacaine hydrochlo-ride 0.5% (Alcaine) was applied 3 times before surgery.In the left eye, a 3.0 mm clear corneal tunnel incisionwas made at 11 o’clock, sodium hyaluronate (Duo-Visc) was injected to stabilize the anterior chamber,a capsule forceps was used to perform a continuouscurvilinear capsulorhexis of 5.0 mm diameter, andphacoemulsification was performed using a stop-and-chop technique. A C21.5 diopter (D) intraocularlens (IOL) (Matrix 401, Medennium, Inc.) was insertedintracapsularly. The effective phaco time (EPT) was 3minutes 20 seconds with a mean ultrasound powerof 27%. The next day, phacoemulsification was per-formed in the right eye and a C21.0 D IOL was im-planted uneventfully using the same procedure. TheEPTwas 2minutes 30 secondswith amean ultrasoundpower of 18%.

The last examination was 3 months after surgery.The uncorrected distance visual acuity (UDCA) was0.8 in both eyes. The patient lived for 4 years aftersurgery.

Case 2

A 105-year-old woman was referred to our hospitalin April 2008 because of blurred vision in both eyes ofmore than 20 years and loss of vision over the previous8 months. On examination, visual acuity was handmotion with accurate perception of light in botheyes. The IOP was 6.4 mm Hg in the right eye and7.3 mm Hg in the left eye and the corneal endothelialcell count, 3460 cells/mm2 and 2652 cells/mm2, re-spectively. Both eyes showed white mature cataracton slitlamp biomicroscopy examination. Atrial fibrilla-tion was detected as a concomitant disease with nosymptoms. General medical examination resultswere otherwise unremarkable.

The patient was too nervous to cope with surgeryunder topical anesthesia, especially during the chop-and-stop phase of phacoemulsification. Surgery inthe first (left) eye was suspended after she moved sud-denly and shook her head violently to the left. It wasrestarted after more proparacaine hydrochloride0.5% drops were applied topically in combinationwith 1.0 mL propofol intravenously administered byan anesthesiologist. Fortunately, the posterior capsulemembrane was intact when surgery was restarted.Surgery was completed with uneventful implantationof a C23.5 D IOL (Rayner Intraocular Lenses Ltd.) un-der topical anesthesia in combination with individual-ized sedation. The EPT was 4 minutes 14 seconds with

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a mean ultrasound power of 27%. The next day, pha-coemulsification with implantation of a 22.0 D IOLwas performed uneventfully under topical anesthesiain the second (right) eye. The EPTwas 1minute 51 sec-onds with a mean ultrasound power of 39%.

On the first postoperative day, the UCDAwas 0.2 inboth eyes. At 6 months, it had improved to 0.6 and thecorneas were clear. The patient is still alive.

DISCUSSION

To our knowledge, these 2 cases are the oldest patientsreported in the literature.We focused on the surgery in105-year-old patients to help surgeons understand thisspecial condition and how to operate on very elderlypatients.

Cataract is the most common treatable blindness inthe world. Surgery is the only effective way to treatcataract, but surgical removal of cataracts in a 105-year-old patient presents special challenges. Data oncentenarians are rare because relatively few patientsin this age group have surgery. Cavanaugh et al.2

have reported a case of a 101-year-old patient withan intraspinal meningioma that was successfully re-moved surgically. For many surgical procedures, therisk for complications is positively correlated to age,while the outcome is negatively correlated with age.Some ophthalmologists may think this also appliesto cataract surgery. Cataract surgery in very elderlypatients is challenging, as most of these patientshave very dense nuclear cataracts. As age advances,there is a gradual reduction in corneal endothelialcell density and a zonule-free zone on the anterior cap-sule,3 possibly predisposing elderly patients to highercomplication rates. Despite these concerns, to ourknowledge, there has been no study of cataract sur-gery in patients of 105 years and older.

Topical anesthesia is a safe and effective method forsmall-incision clear corneal phacoemulsification cata-ract surgery, especially in patients who are at high car-diopulmonary risk for general anesthesia.4 However,the patient’s cooperation is essential in surgery undertopical anesthesia, and this is usually difficult for thenervous patient. General anesthesia should be usedin those who cannot cooperate and are otherwise ingood health, but it should also be remembered thatthe incidence of perioperative systemic complicationsmay increase during general anesthesia.

In conclusion, we found that the very elderly benefitfrom cataract surgery in terms of functional outcomeand that they are satisfied because the surgical out-comes correspond to their expectations. Our experi-ence supports the belief that advanced patient ageshouldnotnecessarilybe consideredacontraindicationto phacoemulsification cataract surgery. A good clini-cal outcome can be expected even under topical

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anesthesia with modern tools and appropriatetechniques as long as there is thorough preoperativepreparation. Because of the increased risk for complica-tions, phacoemulsification in elderly cases should beundertaken only by experienced surgeons.

REFERENCES1. Allen D, Vasavada A. Cataract and surgery for cataract. BMJ

2006; 333:128–132. Available at http://www.ncbi.nlm.nih.gov/

pmc/articles/PMC1502210/pdf/bmj33300128.pdf. Accessed

January 1, 2010

2. Cavanaugh DA, Jawahar A, Lee JA, Wilkinson K, Kerr EJ III,

Nunley PD. Intraspinal meningioma in a 101-year old: should

age determine the aggressiveness of intervention? Surg Neurol

2008; 69:130–134

3. Sakabe I, Oshika T, Lim SJ, Apple DJ. Anterior shift of zonular in-

sertion onto anterior surface of human crystalline lens with age.

Ophthalmology 1998; 105:295–299

4. StuppT,Hassouna I, SoppartK,ThanosS,Forster W.Systemicad-

verse events: a comparison between topical and peribulbar anes-

thesia in cataract surgery. Ophthalmologica 2007; 221:320–325

A survey of the current role of manualextracapsular cataract extraction

Christine K. Chen, Victoria L. Tseng, Wen-Chih Wu, MD,Paul B. Greenberg, MD

Since phacoemulsification can be performed safelywithout prior manual extracapsular cataract extrac-tion (ECCE) training, the current role of manualECCE is unclear.1 The prevalence of and indicationsfor manual ECCE in the United States have not beenexamined recently. Therefore, we surveyed all chiefsof ophthalmology in the U.S. Veterans Health Admin-istration (VHA) regarding the role of ECCE at theirfacilities.

After obtaining a study exemption from the Provi-dence (Rhode Island, USA) VHAMedical Center Insti-tutional Review Board, the 2009 Federal PractitionerDirectory2 was used to identify all VHA facilitieswith ophthalmology services. Each facility was calledto obtain contact information for the chief (or actingchief) of ophthalmology. The chiefs were emailed thelink to an anonymous survey (Table 1) created onwww.surveymonkey.com.

Eighty-eight VHA facilities with ophthalmologyservices were surveyed. The response rate was 42.0%(37/88). Manual ECCEwas performed at 26 of 36 facil-ities (72.2%); a mean of 2.2% G 3.5% of all cataractsurgery cases at these facilities were manual ECCE.The most common reasons for performing manualECCE were dense cataracts (30/37 [81.1%]), need toconvert from phacoemulsification (10/55 [18.2%]),zonular instability (6/37 [16.2%]), and resident train-ing (4/37 [10.8%]). Most of the facilities (29/37[78.4%]) trained ophthalmology residents, but most

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