|Year : 2015 | Volume
| Issue : 1 | Page : 191-196
Phacoemulsification versus manual small incision cataract surgery for treatment of cataract
Saber H El-Sayed1, Hoda MK El-Sobky1, Nermeen M Badawy1, Eslam AA El-Shafy2
1 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt
2 Department of Ophthalmology, National Eye Center Hospital, Cairo, Egypt
|Date of Submission||14-May-2013|
|Date of Acceptance||25-Sep-2013|
|Date of Web Publication||29-Apr-2015|
Eslam AA El-Shafy
12 El-Khateeb Street, El-Kalyobeya Governorate, Benha City
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate the effect of sutureless scleral tunnel manual small incision cataract surgery (MSICS) on the postoperative astigmatism in comparison with the effect of phacoemulsification.
Nonphaco sutureless cataract extraction retains most of the advantages of phacoemulsification with comparable visual outcome and is affordable.
Materials and methods
Phacoemulsification and MSICS were performed in 20 eyes of 20 patients. Both techniques were performed at the Department of Ophthalmology, Menoufia University Hospital, Menoufia Governorate, Egypt. The study was conducted between 1 September 2011 and 28 February 2013. The outcome was evaluated in both techniques in terms of early visual rehabilitation, surgically induced astigmatism, and final best-corrected visual acuity.
Of the 20 patients who underwent phacoemulsification, 60% were male patients and 40% were female patients. Of the 20 patients who underwent MSICS, 45% were male patients and 55% were female patients. Both surgical techniques achieved excellent visual outcomes with low complication rates. The initial visual recovery on the first postoperative day was better in the patients who underwent phacoemulsification, with the uncorrected visual acuity better than or equal to 6/18 in 75% of the patients, whereas the percentage was 60% in the MSICS group. The initial difference was nearly equalized within 4 weeks. At the sixth month, 85% of the patients in the MSICS group had uncorrected visual acuity better than or equal to 6/18 versus 90% of the patients in the phacoemulsification group. The surgically induced astigmatism at the sixth month was comparable in both techniques, 1.18 0.2 D in the phacoemulsification group versus 1.2 0.23 D in the MSICS group.
Both phacoemulsification and MSICS achieved excellent visual outcomes with low complication rates. MSICS is less technology dependent; hence, it is less expensive and more appropriate for treatment of advanced cataracts prevalent in the developing world.
Keywords: Manual small incision cataract surgery, phacoemulsification, surgically induced astigmatism, visual acuity
|How to cite this article:|
El-Sayed SH, El-Sobky HM, Badawy NM, El-Shafy EA. Phacoemulsification versus manual small incision cataract surgery for treatment of cataract. Menoufia Med J 2015;28:191-6
|How to cite this URL:|
El-Sayed SH, El-Sobky HM, Badawy NM, El-Shafy EA. Phacoemulsification versus manual small incision cataract surgery for treatment of cataract. Menoufia Med J [serial online] 2015 [cited 2020 Jan 21];28:191-6. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/191/155987
| Introduction|| |
Cataract is the main cause of avoidable blindness worldwide, with the developing world accounting for more than 60% of patients. Despite the 10-12 million cataract operations performed globally, cataract blindness is still thought to be increasing by 1-2 millions/year .
Developed health systems such as those in Western Europe, North America, and Australia have greatly reduced the prevalence of cataract by establishing an adequate cataract surgical rate (CSR), which refers to the number of cataract operations performed per million populations per year. To eliminate cataract blindness, the CSR needs to equal the incidence (number of new cases) of cataract blindness, which is estimated at ~2000-3000 cases per million populations per year. If the CSR is less than 2000, the surgery rate will not keep up with the incidence; some people who become blind because of cataract will remain untreated and will remain blind until they die, and the backlog will continue to increase. This is the situation in much of the developing world .
To deliver an effective cataract service, wherever it is based, it must be affordable. In more affluent areas of the world, phacoemulsification has become the primary method of performing cataract surgery. There are, however, many areas where phacoemulsification is not appropriate. This possibly involves the majority of cataract blindness in the world today because of density of cataracts involved besides the cost and maintenance demands of the equipment. To effectively address this increasing backlog, significant efforts are being undertaken to increase the output of cataract surgical services in many developing countries and to make cataract surgery affordable to all people irrespective of their economic status .
The main objective in modern cataract surgery is to achieve a better unaided visual acuity with rapid postsurgical recovery and minimal surgery-related complications .
Early visual rehabilitation and better unaided vision can be achieved mainly by reducing the incision size .
The evolution of cataract surgical techniques over the past several decades has been associated with a progressive decrease in the size of the cataract incision. Wound size has progressively decreased from 12.0 mm in intracapsular cataract surgery to about 10.5 mm in early extracapsular surgery and to 5.5-7.0 mm with the advent of phacoemulsification. The widespread use of foldable intraocular lens (IOL) has allowed the cataract wound to decrease to 3.0 mm or smaller .
In the intraoperative management, reduced wound size has several advantages. The smaller the incision, the more stable the anterior chamber with improved control during capsulorhexis and hydrodissection .
During the postoperative period, smaller wounds heal more rapidly with less risk for leakage and a theoretically reduced risk for endophthalmitis .
Manual small incision cataract surgery (MSICS), similar to the extracapsular cataract extraction (ECCE) technique but with its sutureless relatively smaller incision, has similar advantages to phacoemulsification and is affordable. It has evolved as an effective alternative to phacoemulsification in the present times because it combines both sutureless advantages of phacoemulsification with minimum investment .
MSICS has the advantages of small sutureless incisions regarding early wound stability, less postoperative inflammation, and no suture-related complications such as those in conventional ECCE. MSICS also has the advantage of being manual where no ultrasound-related complications such as those in phacoemusification are present .
Moreover, MSICS can be performed in almost all types of cataract in contrast to phacoemulsification where case selection is extremely important for an average surgeon; hence, it is a more appropriate surgical procedure for the treatment of advanced cataract in the developing world .
In phacoemulsification, the duration of surgery, phaco power used, and even the incidence of intraocular complications vary with the nucleus density. In MSICS, the time spent on nucleus delivery does not vary from patient to patient. Hence, the manual small incision techniques are gaining popularity, as they are quick, relatively inexpensive techniques for large-scale cataract management in the developing world .
MSICS is a very promising technique, even in the developed countries. MSICS is more and more being looked upon, not as a 'poor man's phaco' but rather as a viable technique, and in some societies it is a preferable alternative to phacoemulsification. In addition, a background in MSICS will ease the learning curve for phaco, as many steps are common. Mastering MSICS will also help to save a phaco surgery case if one is forced to bail out, and still come out with a respectable sutureless outcome to the surgery .
| Materials and methods|| |
Both phacoemulsification and MSICS were performed at the Department of Ophthalmology, Menoufia University Hospital, Menoufia Governorate, Egypt. The study was conducted between 1 September 2011 and 28 February 2013. Forty eyes of 40 patients were chosen. Twenty eyes were assigned to phacoemulsification with a foldable IOL implantation, and the other 20 eyes were assigned to sutureless scleral tunnel MSICS (manual phaco). Ophthalmic history was taken regarding the onset, course and duration of diminution of vision, history of drug intake for eye diseases, and history of previous eye surgery. Medical history was also taken regarding diabetes mellitus, hypertension, autoimmune disease (such as rheumatoid arthritis), cardiac diseases, and other relevant medical conditions. Preoperative examination included uncorrected visual acuity (UCVA), refraction, best-corrected visual acuity (BCVA), color vision testing, pupillary light reflex testing, slit-lamp examination of anterior segment, intraocular pressure measurement by the Goldmann applanation tonometer, and posterior segment examination. A keratometer was used to detect the steepest and flattest meridian, and the difference between them was the amount of corneal astigmatism and its axis was the axis of the steepest meridian. The informations that were reviewed and documented in this study included patients' sex, age, preoperative and postoperative UCVA and BCVA, preoperative clinical diagnosis, preoperative and postoperative corneal astigmatism and astigmatic axis using keratometric readings, calculating surgically induced astigmatism (SIA), and intraoperative and postoperative complications. Each patient in both groups in this study was followed up on the first postoperative day and 1 week, 1 month, 3 months, and 6 months after operation. BCVA data were categorized as better than, equal, or less than 6/18.
In phacoemulsification, after sterilization and draping and application of a wire speculum, a corneal tunnel using disposable ophthalmic 3.0-mm keratome was made in the upper temporal quadrant of about 2 mm length and 3 mm width. Thereafter, side ports were made using a 20-G disposable ophthalmic microvitreoretinal blade. Adequate amount of ophthalmic viscoelastics was then injected to fill the anterior chamber and to flatten the anterior capsule of the lens for proper subsequent capsulorhexis procedure. Continuous curvilinear capsulorhexis was performed with a self-fashioned cystotome using a bent 24-G needle; if needed, a capsulorhexis forceps was used to complete the procedure, ending with ~6 mm wide capsulorhexis. Hydrodissection then was performed using a 27-G flat tip hydrodissection cannula. After gently elevating the edge of capsulorhexis and advancing the tip of the cannula, a small amount of irrigation fluid was injected slowly and steadily until a wave of hydrodissection was seen on the posterior capsule along with gentle downward compression on the nucleus to prevent capsular block syndrome. In phacoemulsification systems, standard tips with 15° bevel fitted on phaco handpiece were used in all patients. Divide and conquer technique was applied to perform nucleus disassembly under certain parameters. The machine parameters used during making the groove were: power of up to 60% continuous mode, aspiration flow rate of 20-26 ml/min, and vacuum limit of 50 mmHg. Then, the parameters used during quadrant removal were: power of 30-50% pulse mode, aspiration flow rate of 24-28 ml/min, and vacuum of 250-300 mmHg. Irrigation and aspiration (I/A) of the cortical matter was then performed using bimanual I/A props and foot switch. Foldable posterior chamber IOL was implanted into the bag. The IOLs used in all patients were acrylic foldable lens, single piece, 6.0 mm with overall length of 12.5 mm, and the injection was given through an injecting device. Closure of the wound was performed by stromal hydration. Finally, a 1 ml combination of broad-spectrum antibiotic and steroid was injected subconjunctivally.
In MSICS, after sterilization and draping and application of a wire speculum, peritomy was performed superiorly with scissors where the conjunctiva and the Tenon's capsule were dissected separately and bleeding was cleared with a wet-field cautery. For wound construction, a frown incision was made with the tip of a crescent blade at about 1.5-2 mm distance from the limbus. The external width of the incision was about 6-6.5 mm according to the expected size of the nucleus. The incision was dissected forward for 1-1.5 mm into clear cornea with a bevel-up crescent blade. Side port then was made using a 20-G disposable ophthalmic microvitreoretinal blade. The eye was then injected with viscoelastics to fill the anterior chamber. Then, the anterior chamber was entered with a 3.2-mm keratome at the depth of this scleral flap, giving a self-sealing internal flap. Thereafter, additional viscoelastics were injected in the anterior chamber. Continuous curvilinear capsulorhexis was performed with a self-fashioned cystotome using a bent 24-G needle. When needed, a capsulorhexis forceps was used to complete the procedure. The capsulorhexis was performed after injection of a trypan blue dye for cases with mature cataract. Whenever the dye was not available, anterior capsulotomy was performed and was found to be working well. The size of capsulorhexis for the delivery of the nucleus was as large as 8 mm. Complete hydrodissection was performed with the cannula just beneath the anterior capsule to loosen the nucleus and to make it freely rotating. Before nucleus delivery, the 3.2 mm incision was enlarged to 7 mm with the crescent blade attempting to maintain the internal self-sealing incision all the way across. Additional viscoelastics were then injected in the anterior chamber. The nucleus was prolapsed in the anterior chamber by viscoexpression. The nucleus was then removed using the phaco-sandwich technique. After delivery of the nucleus in the anterior chamber and injection of viscoelastics above and below it, the nucleus was sandwiched between two instruments, the lens loop from below and a spatula from above; thereafter, the nucleus was gradually extracted between the two instruments. I/A of the cortex was carried out by Simcoe double-way cannula through the main wound or through the side port for the subincisional cortex. Posterior chamber 6.5 mm PMMA IOL was implanted into the bag. Closure of the conjunctiva was then performed using bipolar cautery or using a single 8-0 nylon stitch if the cautery was not available. Finally, a 1 ml combination of broad-spectrum antibiotic and steroid was injected subconjunctivally.
| Results|| |
With respect to the age, there was a mean age of 60 years with 1.84 SD in the phacoemulsification group versus a mean age of 61 years with 1.25 SD in the MSICS group. With respect to the sex, there were more male patients [14 (60%)] as compared with female patients [6 (40%)] in the phacoemulsification group, but there were more female patients [11 (55%)] as compared with male patients [9 (45%)] in the MSICS group. Both surgical techniques achieved excellent surgical and visual outcomes with low complication rates. The initial visual recovery on the first postoperative day was better in the patients who underwent phacoemulsification, with UCVA better than or equal to 6/18 in 75% of the patients, whereas the percentage was 60% in the MSICS group. The initial difference was nearly equalized within 4 weeks. At the sixth month, 85% of the patients in the MSICS group had better than or equal to 6/18 UCVA versus 90% of the patients in the phacoemulsification group. The mean SIA was comparable in the two groups at 3 and 6 months postoperatively.
The mean SIA in the phacoemulsification group was 1.23 ± 0.32 D at 3 months and 1.18 ± 0.2 D at 6 months. In the MSICS group, the mean SIA was 1.27 ± 0.22 D at 3 months and 1.2 ± 0.23 D at 6 months. There was no significant statistical difference between both groups regarding the mean SIA. Intraoperative iris prolapse occurred in one patient in the phacoemulsification group; one suture was taken, and therefore the patient was excluded from the study. Rupture of posterior lens capsule occurred in one patient in the phacoemulsification group and in one patient in the MSICS group; both patients were managed and excluded from the study. Only one patient with culture-proven endophthalmitis was diagnosed in the phacoemusification group, was managed, and excluded from the study.
There was a case of premature entry into the anterior chamber in the MSICS group, and it was converted to conventional ECCE and excluded from the study. Posterior capsule opacification as a late complication, after 6 months, occurred in three eyes (15%) in the phacoemulsification group versus five eyes (25%) in the MSICS group.
| Discussion|| |
Phacoemulsification is now the preferred technique among most of the eye surgeons all over the world. Another alternative to phacoemusification - MSICS - was shown to get popularity because of its comparable surgical and postoperative outcomes similar to phacoemulsificaion. Furthermore, MSICS has added benefit of being a cheap and affordable technique; hence, it can be used in overcrowded poor communities in which large number of cataract surgeries are needed to be performed to overcome the increasing incidence of blindness in those communities. In this study, the two techniques of cataract surgery were compared from the aspect of their effect on the SIA and subsequently the postoperative visual acuity.
The mean age of the patients was about 60 years in group A and about 61 years in group B; hence, the mean age is nearly similar in both groups. This was important when comparing the astigmatic effect between the two groups, as the relaxing effect of an incision varies with the age of the patient.
With respect to the preoperative visual acuity in this study, it was almost similar in both groups. The visual outcome achieved on the first postoperative day was better in group A in which the patients underwent phacoemulsification where the percentage of patients who achieved UCVA of 6/18 or better was 75%, whereas it was 60% in group B. Both groups achieved good visual results after 6 months, and the difference in UCVA and BCVA between both groups was statistically insignificant.
Ruit et al.  compared the efficacy and visual results of phacoemulsification versus MSICS for the treatment of cataracts. They compared different parameters including UCVA and BCVA. They found that both the surgical techniques achieved excellent surgical outcomes with low complication rates. At 6 months, 89% of the SICS patients had an UCVA of 20/60 or better and 98% had a BCVA of 20/60 or better versus 85% of patients with UCVA of 20/60 or better and 98% of patients with BCVA of 20/60 or better at 6 months in the phaco group. They also mentioned that the surgical time for MSICS was much shorter than that for phacoemulsification, and they concluded that MSICS is an appropriate surgical procedure for the treatment of advanced cataracts.
With respect to the SIA in this study, the mean SIA in group A was 1.23 ± 0.32 D at 3 months after operation and 1.18 ± 0.2 D at 6 months, whereas in group B it was 1.27 ± 0.22 D at 3 months after operation and 1.2 ± 0.23 D at 6 months. There was no significant statistical difference between both groups regarding the mean SIA. This means that both techniques have changed the corneal cylinder but the effect was minimal in both groups.
Gogate et al.  compared phacoemulsification and MSICS with respect to postoperative astigmatism. Average astigmatism for the phacoemulsification group was 1.1 D (0.9 SD) and for the small incision group it was 1.2 D (0.8 SD). Ninety-one of the 185 (49.2%) patients in the phacoemulsification group and 73 of the 187 (39.0%) patients in the small incision group had astigmatism up to 0.75 D. Thus, a significantly less number of patients in the phacoemulsification group had astigmatism of less than 1 D.
Khan et al.  studied the visual outcome and complications of sutureless MSICS. The aim was to determine the SIA and complications of sutureless MSICS. In all, 150 eyes of 134 patients were included in this study. Cataract surgery was performed in all patients as manual sutureless small incision technique. Final BCVA 6 months postoperatively was 6/18 or greater in 86.8% of patients. Astigmatism was noted to be significant or high in 50% patients, which is a large percentage, but the study proved that the course of time has no significant effect on the final amount of postoperative astigmatism in eyes operated by MSICS. Other complications included hyphema noted in 17 (11.3%) patients, posterior capsule rupture in five (3.3%) patients, endophthalmitis in two (1.3%) patients on the first postoperative day. They concluded that MSICS is a safe and effective procedure with rapid visual rehabilitation; the amount of postoperative astigmatism was high in significant number of patients and the final best-corrected visual outcome was good in most of the patients.
Imtiyaz et al.  conducted a study on 115 patients concerned with visual rehabilitation after MSICS. They found that 70 (60.8%) patients improved to an UCVA of 6/12 or better in the third week only and 88 (76.52%) patients had an UCVA of 6/12 or better by the end of 12th week. They found that the commonest cause of an uncorrected vision of less than 6/12 was astigmatism. Of the 27 patients with a visual acuity of less than 6/12 at 12th week, 20 (74%) patients had postoperative against-the-rule astigmatism and seven (26%) patients had postoperative with-the-rule astigmatism. From the above observation, they concluded that patients undergoing MSICS have an early visual rehabilitation. This quick visual restoration is attributed to little inflammation and less SIA [Table 1],[Table 2],[Table 3],[Table 4],[Table 5] and [Table 6].
|Table 3: Postoperative uncorrected visual acuity on first day and at 6 months|
Click here to view
|Table 4: Comparison between the mean preoperative and postoperative corneal cylinder at 6 months in each group|
Click here to view
|Table 5: Comparison between the mean preoperative and postoperative axis at 6 months within each group|
Click here to view
|Table 6: Mean surgically induced astigmatism at 3 and 6 months postoperatively in both groups|
Click here to view
| Conclusion|| |
Phacoemulsification technique has the advantage of early visual rehabilitation after cataract surgery and this is mainly attributed to the small incision size used. However, phacoemulsification is an expensive technique; hence, it is not an affordable technique in the developing countries with very low income. MSICS with its sutureless and relatively smaller incision has similar advantages to phacoemulsification and is affordable; hence, it is a good alternative to phacoemulsification.
In this study using both techniques, it was found that both techniques can give excellent visual results. However, it was found that there is an increased incidence of posterior capsule opacification in the MSICS group.
The occurrence of endophthalmitis confirmed that no technique is immune until now and all available prophylactic measures possible must be used.
There are many surgeons nowadays, especially in the developing countries, who prefer MSICS, whereas others perceive phacoemulsification as the only way, and if failed they convert to the unplanned ECCE. If phacoemulsification is not planned, conversion to MSICS instead of conventional ECCE utilizes the same wound as the phaco one and provides better outcomes than the conventional ECCE.
Transition to phacoemulsification is easier if one has mastered MSICS, as he is familiar with the steps such as sclera pocket incision, capsulorhexis and hydroprocedures. Familiarity with these steps helps to reduce the incidence of complications while learning phaco.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thylefors B, et al.
Global data on blindness: an update. Bull World Health Organ 1995; 73
Foster A. Elimination of cataract blindness. Survey 2000; 45
Limburg H, Vasavada A, Muzumdar G, et al.
Rapid assessment of cataract blindness in urban district of Gujarat. Indian J Ophthalmol 1999; 47
Mitchell PW. Update on bimanual microincisional cataract surgery. Curr Opin Ophthalmol 2006; 17
Ravindran RD, Haripriya A, Minu M. In: Ashok G, Luther L, Geoffery T, et al.
editors. Relevance and clinical significance of SICS (manual phaco) in modern cataract surgery. Clinical practice in small incision cataract surgery (phaco manual)
. 1st ed. Jaypee Brothers; 2005. 238-240.
Soscia W, Howard JG, Olson RJ. Micro-phacoemulsification with White Star: a wound-temperature study. J Cataract Refract Surg 2002; 28
Tsuneoka H, Shiba T, Takahashi Y. Feasibility of ultrasound cataract surgery with a 1.4 mm incision. J Cataract Refract Surg 2001; 27
Naus NC, Luyten GPM, Stijnen T, et al.
Astigmatism and visual recovery after phacoemulsification and conventional extracapsular cataract extraction. Doc Ophthalmol 1995; 90
Gogate PM, Deshpande M, Wormald RP. Is manual small incision cataract surgery affordable in the developing countries? A cost comparison with extracapsular cataract extraction. Br J Ophthalmol 2003; 87
Steinert RF, Brint SF, White SM, et al.
Astigmatism after small incision cataract surgery: a prospective, randomized, multicenter comparison of 4- and 6.5-mm incisions. Ophthalmology 1991; 98
Ronnie G, Pankaj R, Sripriya AV, Rajesh PS, Smita P. Comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery and phacoemulsification. Ophthalmic Epidemiol 2005; 12
Nikhilesh T. In: Ashok G, Luther L, Geoffery T, et al
.editors. Blumenthal′s technique in MSICS: a 100% approach. Clinical practice in small incision cataract surgery (phaco manual).
1st ed. ?: Jaypee Brothers; 2005. 344-352.
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
Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD, Joshi SA, Palimkar A, et al.
Safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial: six week results. Ophthalmology 2005; 112
MT Khan, S Jan, Z Hussain, S Karim, MK Khalid. Visual outcome and complications of manual sutureless small incision cataract surgery. Pak J Ophthalmol 2010; 26
Ahmed I, A Wahab, S Sajjad, RA Untoo. Visual rehabilitation following manual small incision cataract surgery. JK Sci 2005; 7
Gogate, Deshpande M, PK Nirmalan. Is manual small incision cataract surgery as safe for the cornea as phacoemulsification 2008; 114
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]