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Cataract surgery, their postoperative analysis, and a comparison of phacoemulsification and manual small-incision cataract surgery at a tertiary care hospital: A retrospective study

 Department of Ophthalmology, Adesh Medical College and Hospital, Shahbad, Haryana, India

Date of Submission27-Jan-2021
Date of Decision30-Apr-2021
Date of Acceptance05-Jul-2021

Correspondence Address:
Sujit Das,
Department of Ophthalmology, Adesh Medical College and Hospital, Near Ambala Cantt, Vill-Mohri, Shahbad - 136 134, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_54_21


In this modern era, though some of us start our surgical career with phacoemulsification (PHACO), still today, some scholars believe that manual small-incision cataract surgery (MSICS) has the similar efficacy with PHACO. Objectives: The study objective was to analyze cataract surgery outcomes in terms of vision, complications, and postoperative quality of life. Study Design: This is a retrospective study. Materials and Methods: All surgeries were performed under peribulbar block. Lens power calculation was done by A-scan. Glaucoma, corneal pathology, pterygium, uveitis, and all the posterior-segment pathology cases were excluded from the study. The total follow-up duration was 6 weeks. MSICS was strictly performed for mature cases. Results: Out of 336 cases, MSICS was performed in 151 cases, whereas PHACO was performed in 185 cases. The majority of cases was between 61 and 70 years of age. After 6 weeks, the minimum cylindrical number was encountered as − 0.75 D in small-incision cataract surgery (SICS) and − 0.5 D in PHACO. Visual acuity of 6/6 was found in 6.6% (n = 10) cases of SICS and 15.6% (n = 29) cases of PHACO. The levels of visual acuity after cataract surgery were categorized using the World Health Organization (WHO) guidelines with good outcome being 6/6–6/24, borderline outcome being 6/24–6/60, and poor outcome being < 6/60. According to the WHO guideline, good vision was present in 84.10% (n = 127) and 97.83% of cases of SICS and PHACO, respectively. Postoperative day 1 cornea was found absolutely clear in 91.97% (n = 336) of cases (P < 0.001). There was not a single case of endophthalmitis. Nucleus drop was seen in one case of PHACO. Conclusions: Visual acuity of 6/6 can be provided to SICS patients, and there is no need to try PHACO especially in intumescent white, black, and brown cataract cases.

Keywords: Cataract surgery, ocular blindness, phacoemulsification, small-incision cataract surgery

How to cite this URL:
Das S, Shergill SS. Cataract surgery, their postoperative analysis, and a comparison of phacoemulsification and manual small-incision cataract surgery at a tertiary care hospital: A retrospective study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=332009

  Introduction Top

Cataract is a major cause of avoidable blindness, many of which become intumescent, mature, and hypermature because of unawareness. Among the various causes, senile cataract is the most common. Lens-induced (phacomorphic and phacolytic) glaucoma is a common complication, which ultimately causes irreversible blindness.[1] There are so many new approaches for cataract surgery, but still manual small-incision cataract surgery (SICS) and phacoemulsification (PHACO) are the common surgical methods applied.[2] Some scholars believe that manual small-incision cataract surgery (MSICS) has the similar efficacy with PHACO.[2] In PHACO, the eye surgeon creates a small incision (generally 2.8 mm), whereas in SICS, a large incision, generally 6.5–7 mm is made. Hence, the chance of postoperative astigmatism is higher in SICS.[2] In PHACO, clear corneal incisions are made and the broken-up pieces of lens are suctioned out of the eye with the help of a costly Phaco machine, whereas in SICS, scleral incisions of different design are made manually.[2],[3]

In this study, individual data were grouped for the following objectives: uncorrected and best-corrected visual acuity (BCVA) at 6/18 cutoff (<6/18 vs. ≥6/18), uncorrected and BCVA at 6/9 cutoff (<6/9 vs. ≥6/9), uncorrected visual acuity (UCVA) 6/60 cutoff (<6/60 vs. ≥6/60), postoperative astigmatism, intraoperative and postoperative complications, and duration of surgery. In the present study, our aim is to compare PHACO and MSICS in terms of visual acuity, postoperative astigmatism, and operative complications.

  Materials and Methods Top

A total of 336 cataract patients participated in this study, and the total duration of the study was 8 months from May 2020 to December 2020. The inclusion criteria were all uncomplicated cataract cases who required surgery. Glaucoma, corneal pathology, pterygium, uveitis, and all posterior-segment pathology cases were excluded from the study. SICS was strictly preferred for intumescent cataract, mature cataract, and hypermature cataract.

Keratometric readings were taken using an autorefractomer. Lens power calculation was done by A-scan. Polymethylmethacrylate lens of 6-mm diameter was used for SICS and foldable lens was used for PHACO. Preoperatively, unaided and BCVA was taken using Snellen's charts, and intraocular pressure was measured using Goldmann's applanation tonometer. Detailed slit-lamp examination includes any corneal pathology, pseudoexfoliation, synaechia, IRIS trophy, pupilary dilatation, and anterior chamber (AC) depth. A detailed posterior-segment examination was done by indirect ophthalmoscopy and a 90 D Lens.

Ultrasonography was performed where fundus was not visible. Complete blood count, blood pressure, blood sugar (fasting and postprandial), urine routine, electrocardiogram, and xylocaine sensitivity were checked in all cases preoperatively.

The day before surgery, all patients were given tablet ciprofloxacin (500 mg) 1 tablet twice a day along with eye drop moxifloxacin 1 drop four times a day in both the eyes. The eyes were dilated with tropicamide and phenylephrine 1 h prior to surgery. After surgery, the eye was patched for 24 h after administering moxifloxacin and prednisolone acetate eye drop. Each patient was followed up on day 1, day 7, day 14, and finally after 6 weeks. All of them were given an eye drop moxifloxacin plus prednisolone acetate combination 1 drop six times a day with gradual tapering over a period of 6 weeks. Postoperatively tablet ciprofloxacin was continued for 5 days. For those who had postoperative moderate corneal edema and raised intraocular pressure, eye drop Hypersol (sodium chloride 5%) 1 drop five times a day, eye drop Homatropine (2%) one drop thrice daily, and Timolol (0.5%) one drop twice a day were added. Tablet prednisolone (1 mg/kg/bwt) along with eye drop Homatropine (2%) one drop thrice daily and Timolol (0.5%) one drop twice a day were reserved for those who will develop severe AC reaction.

All PHACO surgeries were performed from the temporal side using two side ports 180° apart at 12° clock and 6° clock positions using a 15° blade. The main port was made at 3° and 9° clock positions (clear corneal and two planner incisions) using a 2.8-mm blade. All SICSs were performed from the superior side after applying bridle suture. Central frown-shaped 6–7 mm incisions were made in the majority of cases, whereas straight incisions were preferred in the cases of hypermature and black–brown cataract.

Random blood sugar below 200 mg/dL without any retinopathy and blood pressure maximum of 160/100 mmHg without hypertensive retinopathy were considered for all cases. Final glass was given after 6 weeks. All the surgeries were performed by a single surgeon (Dr. Sujit Das).

The medical center's ethics committee approved the study protocol. All patients provided written informed consent before enrollment in the study. All the data were analyzed using SPSS software (Statistical Package for The Social Sciences [Ibm in 2009, Current Version 2027, Current Name IBM Spss Statistics, [IBM-International Business Machines Corporation, A American Company, New York), and the outcomes were studied by using the percentages. Statistical heterogeneity was tested using the Chi-square test. Parameters of PHACO group were compared to the respective parameters of the SICS group. Paired t-test was used to test the significance of each comparison.

  Results Top

The total number of patients included in this study was 336. Majority of the patients were aged between 61 and 70 years (SICS = 67, PHACO = 66) [Table 1]. Male and female patients participated in our study were 52.08% (n = 75) and 47.91% (n = 161), respectively. Compared to left eye, right eye surgery was maximized, 60.11% (n = 202). Shallow AC depth was present in 21 cases, whereas intraoperative floppy iris was found in 44 cases. Within the capsular bag, a total of 331 intraocular lenses (IOLs) were placed, whereas within the sulcus, five IOLs were placed. During surgery, posterior capsular rupture occurred in four cases (Phaco = 03, SICS = 01), whereas superior iridodyalysis, inferior iridodyalysis, and Argentina flag sign were noticed in one case each.
Table 1: Age Distribution

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On postoperative day 1, the absolute clear cornea was found in 91.97% (n = 309) of cases, whereas mild edema was noticed in 13 cases and moderate corneal odema in 14 cases. On postoperative day 1, mild AC reaction was found in 76.49% (n = 257) of cases, whereas there was moderate AC reaction in 13 cases. Fundal glow was very good on day 1. There was not a single case of subluxated intraocular lens or endophthalmitis in our study. Corneal edema and AC reaction were all cleared on day 7.

Postoperatively, papillary distortion and open sclera tunnel were noticed in one case. Scleral tunnel was sutured, and the pupil was made circular. In case of PHACO, there was a single case of iatrogenic iris injury and nucleus drop. A nucleus drop patient was referred to a vitreo-retinal surgeon for further management.

The mean surgical time was 12.11 min in the case of SICS and 12.38 min in the case of PHACO in our study. In our study, there were no statistically significant differences between pre- and postoperative keratometric values [Table 2]. Preoperative visual acuity [Table 3] and postoperative visual improvement were quite significant [Table 4] in our study. Paired sample statistics [Table 5] of both the surgical procedures showed significant visual acuity improvements on each follow-up (paired t-test; P < 0.001).
Table 2: Keratometry

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Table 3: Preoperative visual acuity

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Table 4: Postoperative visual acuity

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Table 5: Pre and post operative visual acuity analysis and their pair t test both SICS and PHACO surgery

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  Discussion Top

Cataract extraction should comprise the following features in all types of cataract surgical procedures: inexpensive and affordable, early rehabilitation to avoid economic loss, near-emmetropic visual status postoperatively, minimal complications AND SHOULD HAVE minimal wound suturing.[4] Phaco and SICS offer all these merits in settings where they have been widely used.[5] The SICS technique is universally acclaimed as being more economical and suitable for high-volume surgeries. The technique is not only cost-effective, but has also shown to be a better alternative to Phaco in some cases, such as in operating on hard, white, and brown–black cataracts and lens-induced glaucomas.[6]

Levels of visual acuity after cataract surgery had been categorized using the World Health Organization (WHO) standards. The WHO classifies visual acuity of 6/18 and better vision as normal vision, borderline outcome as 6/24–6/60, and 6/60 as severe visual impairment (economic blindness).[7] In the present study, 94.7% of the SICS group (n = 143) and 98.91% of the PHACO group (n = 183) had a good outcome, whereas 5.9% of the SICS group (n = 9) and 0.5% of the PHACO group (n = 1) had borderline outcome. After 6 weeks of follow-up, there was unaided visual acuity of 6/9 in 27.15% (n = 41) of SICS and 61.08% (n = 113) of PHACO cases. Unaided visual acuity of 6/6 was found in 6.6% (n = 10) of SICS and 15.6% (n = 29) of PHACO cases. There was unaided visual acuity of 6/12 in 34.43% (n = 52) and 16.21% (n = 30) of cases of SICS and PHACO, respectively. Unaided visual acuity of 6/18 was noticed in 15.89% (n = 24) cases of SICS and 4.86% (n = 9) cases of PHACO. Visual acuity of 6/18–6/36 was mainly found in the straight incision group of SICS.

Zawar and Gogate[8] and Gogate et al.[9] in their study on 2000 eyes undergoing manual SICS found that 93.4% of eyes achieved a final BCVA better than 6/12 at 6 weeks postoperatively, whereas Rohatgi et al.[3] found that 93.3% of the patients had BCVA of 6/18 or better at 8 weeks after SICS with central frown incision. In our study on 151 eyes undergoing manual SICS, 54.3% (n = 82) of eyes achieved a final BCVA of 6/9 at 6 weeks postoperatively, whereas it was 6/6 in 12.6% (n = 19) and 6/18 in 13.9% (n = 21) of cases. Among the PHACO group of 185 eyes, the final BCVA of 6/9 at 6 weeks postoperatively was 49.7% (n = 92), whereas it was 6/6 in 45.9% (n = 85) and 6/18 in 2.7% (n = 5) of cases. The BCVA percentage at 6 weeks in our study is comparable with that of Zawar and Gogate[8] and Gogate et al.[9].

A study conducted by Venkatesh et al.[10] observed that 1-day postoperative UCVA was better in 48.9% in PHACO group and 51.1% in SICS group, and the difference was not statistically significant. At 6 weeks of follow-up, 87.6% in the PHACO group and 82.0% in the SICS group had a UCVA of 20/60 or better, and the difference was not statistically significant. Gogate[11] observed that 68.2% of the PHACO group and 61.3% of the small incision group had better (6/6–6/18) uncorrected vision at the 1-week follow-up (P = 0.153). Paired–t-test analysis of UCVA in our study (day 1 and postoperative 6 weeks) showed that the unaided visual acuity improvement in both the groups was quite significant (P < 0.001). In our study, both the PHACO and the small incision groups had better (6/6–6/18) uncorrected vision at the 1-week follow-up and was quite significant (P < 0.001). In our study, UCVA in the 1st postoperative week in both the groups was good, and the difference was found to be not statistically significant.

A study conducted by Randeri et al.[12] in 2008 concluded that the central frown incision had reported induced astigmatism of < 1 D in only 28.57% of patients, whereas a majority of the patients (42.85%) had surgically induced astigmatism between 1.25 and 2 D. In our study, frown incision was given in 49% (n = 74) of the cases, and they showed induced astigmatism of < 1 D (mean = −0.9). In the PHACO group (n = 185), all patients underwent temporal incision, with resultant induced astigmatism being <1 D (mean = −0.18). In manual SICS by 6-mm straight incision, Jha and Vats[13] reported that 85.5% of patients had astigmatism of up to 1 D, whereas 8.7% of cases had astigmatism of > 2 D. In our study, after 6 weeks, minimum cylindrical number in the case of SICS and PHACO was − 0.75 D and − 0.5 D, respectively (auto-refractometer reading).

On the 1st postoperative day, in the SICS group, there may be a risk of corneal edema, as most maneuvers are performed in the AC closer to the corneal endothelium, unlike Phaco, where most actions should take place in the capsular bag.[14] However, a randomized controlled trial comparing endothelial cell loss by both techniques did not find any significant difference and concluded that SICS was as safe for the corneal endothelium as Phaco.[15] The success rate of visual acuity correlated with the absence of severe corneal edema. Venkatesh et al.[10] showed that the MSICS group had less corneal edema than the PHACO group (5% vs. 25%, respectively) on the 1st postoperative day. In our study, on postoperative day 1, clear cornea was found in 84.10% (n = 127) of cases of SICS and 98.37% (n = 185) of cases of PHACO, which was statistically significant (P ≤ 0.001), and no difference was found between the MSICS and PHACO groups.

In our study, on postoperative day 1, the very mild AC reaction was noticed in 85.43% (n = 129) of cases of SICS and in 69.18% (n = 128) of cases of PHACO surgery, respectively, which was statistically significant (P ≤ 0.001). The first post operative day visual outcomes as well as complications like post operative corneal odema and anterior chamber reactions were similar to thje study of Venkatesh et al.[10] Complications are still implicated which range from a minor inflammation of the eye following surgery to devastating visual loss due to infection, bleeding in the eye, pseudophakic bullos keratopathy, macular edema, surgery-induced glaucoma, and retinal detachment.[16],[17] There was not a single case of severe AC reaction, bleeding in the eye, pseudophakic bullos keratopathy, macular edema, surgery-induced glaucoma, retinal detachment, and endophthalmitis in our study. More than 98% of patients do not suffer surgical complications, and more than 95% have improved vision Lawrence et al.[18] Poorer visual outcome is usually predicted by older age, poor preoperative visual acuity, and coexisting ocular comorbidity.[19],[20]

In our study, the mean surgical time was 12.11 min in the case of SICS and 12.38 min in the case of PHACO. The average time for PHACO and SICS was recorded in the Pune study[13] as 15 min 30 s and 8 min 35 s, respectively. Venkatesh et al.[10] showed an average time for SICS of 3.75 min per case. Time is not a factor while dealing with mature, hypermature, and black cataracts along with pseudoexfoliations to give better postoperative results.[21]

  Conclusions Top

This study showed that both SICS and PHACO had very good visual outcomes with minimal complications. In the cases of advanced cataracts, we can provide very good postoperative vision after SICS, and there is no need to try PHACO procedure considering the various surgical complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kongsap P. Visual outcome of manual small-incision cataract surgery: Comparison of modified Blumenthal and Ruit techniques. Int J Ophthalmol 2011;4:62-5.  Back to cited text no. 1
Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, et al. A prospective randomized clinical trial of phacoemulsification vs. manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007;143:32-8.  Back to cited text no. 2
Rohatgi J, Gupta VP, Sangma D. A prospective randomized comparative study of manual SICS using 6 mm frown versus 5 mm modified chevron incision. AIOS Proc 2008;28:68-72.  Back to cited text no. 3
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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