From Phacoemulsification To Small Incision Cataract Surgery: A Journey

Most developed countries start cataract surgery training with phacoemulsification. However, phacoemulsification is not always the most suitable form of cataract surgery despite the availability of equipment and technology. Cataracts which are mature and brunescent tend to have higher complication rates for beginner phacoemulsification surgeons. Manual small incision cataract surgery (MSICS) can also be a viable alternative for mature cataracts in developed countries.

This aim of this study is to compare the outcomes of cataract surgery (phacoemulsification vs MSCIS) in dense cataracts when a phacoemulsification surgeon transitions from phacoemulsification to small incision cataract surgery.

Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India

A cataract surgeon with 5 years of phacoemulsification experience from a developed country travelled to a tertiary eye hospital in Madhya Pradesh, India to learn MSICS. This training was conducted over a period of 3 months and included didactic lectures, observation and supervised hands-on training. Mature senile cataracts (graded at least NS4 on LOCS III) were chosen and patients were randomised to either phacoemulsification or MSICS. The total number of cases, complication rates and visual outcomes were recorded and compared. A logbook of challenges faced was also kept.

A total of 120 eyes underwent cataract surgery, of which 58 (48.3%) underwent phacoemulsification and 62 (51.3%) underwent MSICS. There was no difference in gender, age and pre-operative visual acuity (p=0.09). There was a higher proportion of patients in the MSICS group (77.6%) which had good visual acuity (6/6 – 6/18) on the first postoperative day, compared to the phacoemulsification group (52.1%) p = 0.03. Mean visual acuity at 1 week post operatively was 0.43 ± 0.27 in the phacoemulsification group and 0.47 ± 0.24 in the MSICS group. Mean surgery time was significantly shorter in MSICS group (p=0.003). Complication rates of zonulysis, PCR and dropped nucleus were comparable between both groups.

MSICS has been shown to be a good alternative to phacoemulsification. When performing surgery on mature senile cataracts, it has superior visual outcomes on post-operative day 1 and comparable visual outcomes on post-operative week 1. Surgery time is shorter and complication rates are comparable despite being a beginner MSICS surgeon. Challenges faced include constructing a scleral tunnel of an adequate size, width and depth especially when dealing with large nuclei. This could be due to most phacoemulsification surgeons performing clear corneal incisions, and not having much experience with gauging depth in scleral incisions.