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92 Original article
Phacoemulsification versus manual small incision cataract
surgery in hard nuclear cataracts
Hesham A. Enany
Department of Ophthalmology, Faculty of
Medicine, Zagazig University, Zagazig, Egypt
Correspondence to Hesham A. Enany, MD
Ophthalmology, Department of Ophthalmology,
Faculty of Medicine, Zagazig University,
Zagazig 44519, Egypt Tel: +20 106 644 1216;
fax: +20 552 346 893;
e-mail: hesham.enany@yahoo.com
Received 14 May 2017
Accepted 21 September 2017
Delta Journal of Ophthalmology
2018, 19:92–98
Introduction
The main objective in modern cataract surgery is to
achieve a better unaided visual acuity with a rapid
postsurgical recovery and reduced intraoperative and
postoperative complications [1].
Hard brown cataract is a risk factor for intraoperative
complications during phacoemulsification in the
hands of surgeons who deal with such cataract
occasionally. It is still a challenge for experienced
surgeons. The chances of conversion into
extracapsular cataract extraction (ECCE) are higher
than soft and medium-hard nuclei because of the
damage to intraocular tissues produced by surgical
trauma during emulsification of hard and large
nuclei [2].
Phacoemulsification has become the routine procedure
for cataract extraction in the developed countries,
where rehabilitation of the patient is very fast,
© 2018 Delta Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
Purpose
The aim of this study was to compare the clinical outcomes of phacoemulsification
with that of manual small incision cataract surgery (MSICS) in cases of hard nuclear
cataract.
Patients and methods
Eighty eyes of 80 patients with gradual painless diminution of vision, diagnosed as
senile nuclear cataract grade 4 or higher according to Lens Opacities Classification
System III (brown cataract), were studied. These eyes were divided randomly into
two groups: group A included 40 eyes treated by phacoemulsification by the vertical
chopping technique and group B included 40 eyes treated by MSICS by the
viscoexpression technique.
Results
One day postoperatively, the corrected distance visual acuity was at least 6/18 in 21
(52.5%) patients in the MSICS group and in nine (22.5%) patients in the
phacoemulsification group. The difference was statistically significant (P=0.01).
A postoperative increase in intraocular pressure was recorded in one (2.5%) case in
the phacoemulsification group. On the first postoperative day, 11 (27.5%) cases in
the MSICS group and 13 (32.5%) cases in the phacoemulsification group
developed postoperative iritis, with no statistically significant difference between
both the groups.
Conclusion
Both phacoemulsification and MSICS achieved comparable and excellent visual
outcomes for treatment of hard brown cataract, with lower complications rates and
earlier postoperative visual rehabilitation in small incision cataract surgery.
Keywords:
cataract, manual small incision cataract surgery, phacoemulsification, small incision cataract
surgery
DJO 19:92–98
© 2018 Delta Journal of Ophthalmology
1110-9173
associated with good visual outcomes. It offers the
advantages of faster and more predictable wound
healing, reduced discomfort to patients, fewer wound
complications, and less changes of postoperative
astigmatism than conventional ECCE [3].
Modern ECCE surgery involves removal of the lens
fibers, which form the nucleus and cortex of the
cataract, leaving the posterior epithelial capsule to hold
the new artificial intraocular lens (IOL) and keep the
vitreous humor away from the anterior chamber.
Extracapsular techniques of cataract extraction surgery
originally involved manual nuclear expression. Phaco-
emulsification is a mechanically assisted extracapsular
technique of cataract extraction surgery [4].
This is an open access journal, and articles are distributed under the terms
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DOI: 10.4103/DJO.DJO_37_17
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Manual small incision cataract surgery (MSICS)
is characterized by early wound stability, less
postoperative inflammation, no suture-related
complications, few postoperative visits, and less
damaging effect on the corneal endothelium.
Moreover, MSICS can be performed in almost all
types of cataract in contrast to phacoemulsification,
where case selection is extremely important for
junior surgeons [5].
Studies on normal population to assess the response of
the endothelium to cataract surgery have shown a
decrease in the endothelial density over a 3-month
period postoperatively with an increase in the
coefficient of variation and decrease in the
percentage of hexagonal cells [6].
In developing countries such as India and Egypt,
where there is a cataract backlog, MSICS with IOL
implantation promises to be a viable cost-effective
alternative to phacoemulsification [7]. In Egypt,
MSICS is less dependent on technology; hence, it is
less expensive and more appropriate for the treatment
of advanced cataracts [8].
The aim of this study was to compare the clinical
outcomes of phacoemulsification with that of
MSICS in cases with hard nuclear cataracts.
Patients and methods
Eighty eyes of 80 patients were chosen from the
outpatient clinic of the Ophthalmology Department
at Zagazig University Hospitals. These patients
had gradual painless diminution of vision, diagnosed
as senile nuclear cataract grade 4 or higher
according to Lens Opacities Classification System
III (brown cataract) [9]. The eyes were divided
randomly into two groups: group A included
40 eyes treated by phacoemulsification by the vertical
chopping technique and group B included
40 eyes treated by MSICS by the viscoexpression
technique.
Exclusion criteria
Patients younger than 40 years, with dislocated and
subluxated lenses, corneal diseases (congenital
anomalies, degeneration, dystrophies, peripheral
thinning, and conditions with a low endothelial
count), ocular inflammations such as scleritis, patients
with chronic open-angle glaucoma, poorly dilated
pupils, a history of previous intraocular surgeries, and
systemic disorders such as bleeding disorders were
excluded from the study.
Hard nuclear cataract phacoemulsification Enany 93
Preoperative examination
The history obtained from the patients included name,
age, sex, history of any medical disease, especially
diabetes and hypertension, and a history of any
previous operation (ocular or systemic). A careful
ophthalmologic examination was performed for each
case in the form of measurement of distance visual
acuity, slit-lamp examination for assessment of the
cornea, anterior chamber depth, regularity of the
pupil, nuclear hardness, measurement of intraocular
pressure using a Goldmann applanation tonometer,
and measurement of keratometric readings. After
pupillary dilatation, nuclear grading was performed
according to Lens Opacities Classification System
III and fundus examination was performed using a
+20 D lens for indirect ophthalmoscopy and a +90 D
lens for slit-lamp fundus biomicroscopy if possible to
exclude any retinal pathology. A-scan to measure
the axial length and keratometry to measure the
corneal refractive power were performed for IOL
power calculation using the SRK II formula
[P=A1−BL−CK, where P is the implant power for
emmetropia, L is the axial length (mm), K is the
average keratometry, and A, B, and C are constants]
and B-scan ultrasonography was performed to
evaluate the posterior segment if it was could not be
visualized properly because of the dense cataract.
This was followed by measurement of central corneal
thickness. Dual-scanning corneal tomography (Sirius
System; Costruzione Strumenti Oftalmici, Firenze,
Italy) and specular microscopy (Topcon Specular
microscope, Sp-2000P; Topcon Inc., Tokyo, Japan)
(endothelial images) were performed at baseline
(preoperatively) and postoperatively at 1 and 8 weeks.
All parameters were tabulated. Comparison of mean
changes in the central corneal thickness, cell density,
coefficient of variation, and SD; both within and
between groups, 1 and 8 weeks; as compared to baseline
were performed with 95% level of significance (P<0.05).
Pupillary dilatation was performed by topical admini-
stration of phenylephrine hydrochloride 2.5% eye drops
and cyclopentolate hydrochloride 1% eye drops.
Both operative procedures were performed under local
anesthesia by the ophthalmologist. Surface anesthetic,
benoxinate 0.4% eye drops, was administered once just
before the operation.
Surgical techniques
Group A included 40 eyes treated by phaco
emulsification by the vertical chopping technique as
shown in Fig. 1.
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94 Delta Journal of Ophthalmology, Vol. 19 No. 2, April-June 2018

Figure 1

Phacoemulsification by the vertical chopping technique. A: Corneal incision; B: Chopping; C: Bimanual IA; D: IOL implantation; E: Stromal
hydration. IOL, intraocular lens.

Group B included 40 eyes treated by MSICS by the The procedures followed were in accordance with the
viscoexpression technique as shown in Fig. 2. The ethical standards of the institutional review board
conjunctiva was closed by cauterization at the end of (IRB). Approval of IRB and informed consent from
surgery. adult participants were obtained.

Follow up
Patients were examined on the first postoperative day,
and after 1, 2, 4, and 8 weeks.
Statistical analysis
SPSS 13.0 (SPSS Inc., Chicago, Illinois, USA) was
used. The independent-samples t-test and χ 2 were
used. The test was considered significant if P is less
than 0.05, highly significant if P is less than 0.01, and
not significant if P is more than 0.05.
Results
Eighty patients undergoing cataract surgery were
included in this study. Patients were divided into two
groups: group A included those patients who underwent
phacoemulsification and group B included those patients
who underwent MSICS (Table 1).
Intraoperative complications in both groups were
recorded. The difference between both groups in
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Hard nuclear cataract phacoemulsification Enany 95

Figure 2

Manual small incision cataract surgery. A: Scleral cauterization; B: Scleral incision; C: Tunneling with crescent blade; D: Side port with Keratome;
E: Entry of Keratome in AC; F: Tunnel enlargement; G: Capsulorhesis; H: Hydrodissection; I: Rotation with Sinski hook; J: Viscoexpression; K: IA
of the cortex; L: IOL implantation. AC, anterior chamber; IOL, intraocular lens.

Table 1 Patients’ data

Parameters Groups t-test P
PHACO MSICS
Mean age (years) 63.1 65 0.885 0.634 (NS)
Sex (%)
Male 70 65 χ 2=0.741 0.258 (NS)
Female 30 35
Preoperative IOP (mmHg) 14.6±2.1 14.8±1.9 0.5 0.620 (NS)
Preoperative CDVA (%)
6/60–3/60 67.5 62.5 χ 2=0.741 0.258 (NS)
3/60–HM 32.5 37.5
CDVA, corrected distance visual acuity; HM, hand movement; IOP, intraocular pressure; MSICS, manual small incision cataract surgery;
PHACO, phacoemulsification.

failed continuous curvilinear capsulorhexis (CCC)
was insignificant (P=0.08), whereas the difference
in posterior capsule rupture (PCR) (P=0.021) and
conversion to ECCE was significant (P=0.001)
(Table 2).
The difference between both groups in postoperative
corneal edema, by slit-lamp and specular microscopy
and Sirius dual-scanning corneal tomography
according to corneal thickness, in 1 and 8 weeks was
insignificant (P=0.369, Table 3).
A postoperative increase in the intraocular pressure was
recorded in one (2.5%) case in the phacoemulsification
group.
Postoperative iritis was observed on the first postoperative
day in 11 (27.5%) cases in the MSICS group and 13
(32.5%) cases in the phacoemulsification group, a
statistically insignificant difference (P=0.258, Table 4).
The mean difference in central corneal thickness at
baseline and at 1 week postoperatively, between groups
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96 Delta Journal of Ophthalmology, Vol. 19 No. 2, April-June 2018

Table 2 Intraoperative complications

Complications PHACO [n (%)] MSICS [n (%)] χ2 P
Failed CCC 4 (10) 3 (7.5) 1.335 0.08 (NS)
PCR and VL 5 (12.5) 2 (5) 3.556 0.021 (S)
Premature entry 0 1 (2.5)
Button-hole 0 3 (7.5)
Wound burn 5 (12.5) 0
Conversion to ECCE 8 (20) 0 5.228 0.001 (S)
CCC, continuous curvilinear capsulorehexis; ECCE, extracapsular cataract extraction; MSICS, manual small incision cataract surgery;
PCR, posterior capsule rapture; PHACO, phacoemulsification; S, significant; VL, vitreous loss.

Table 3 Postoperative corneal edema

Corneal edema Corneal edema grading P
None Mild Moderate Severe
PHACO group (day 1) 0 6 24 10 0.001 (S)
MSICS group (day 1) 0 20 18 2
PHACO group (week 1) 28 8 3 1 0.369 (NS)
MSICS group (week 1) 36 4 0 0
PHACO group (week 8) 38 1 0 1 0.369 (NS)
MSICS group (week 8) 40 0 0 0
MSICS, manual small incision cataract surgery; PHACO, phacoemulsification; S, significant.

Table 4 Postoperative iritis
PHACO MSICS
Postoperative iritis [n (%)] 13 (32.5) 11 (27.5)
MSICS, manual small incision cataract surgery; PHACO,
phacoemulsification.
A and B, was statistically significant (P=0.024).
However, the difference between the baseline value
and the 8- and 1-week with 8-week was not statistically
significant (Table 5).
The difference between both groups in cell density at 1
and 8 weeks was insignificant (P>0.05, Table 6). The
mean coefficient of variation and the mean±SD
between groups were also not statistically significant
(P>0.05, Table 7).
One day postoperatively, the corrected distance visual
acuity was at least 6/18 in 21 (52.5%) patients in the
MSICS group and nine (22.5%) patients in the
phacoemulsification group; the difference was
statistically significant (P=0.01, Table 8).
Discussion
MSICS is comparable to phacoemulsification for the
rehabilitation of the patient with cataract. It is
recommended as an alternative to phacoemulsification
wherever the required equipment and experience are
not available. A hard brown cataract is a well-known
risk factor for intraoperative complications during
phacoemulsification.
Venkatesh et al. [10] reported that both surgical
P techniques achieved good visual outcomes and both
0.258 (NS) groups had a comparable corrected distance visual
acuity of at least 6/18 2 months postoperatively
(92.5 vs. 85%, P=0.36). In the present study,
uncorrected distance visual acuity of at least 6/18 2
months postoperatively was achieved in 85 and
75% of the patients, respectively. Gogate et al.
[11] reported that both phacoemulsification and
small incision techniques were safe and effective for
visual rehabilitation of cataract patients, although
phacoemulsification yields better uncorrected
visual acuity in a larger population of patients at
6 weeks.
In the present study, the common complication rates
were statistically significantly higher in the phaco-
emulsification group than in the MSICS group (15 vs.
25%, respectively). Haripriya et al. [12] analyzed the rate
of intraoperative complications, reoperations, and
endophthalmitis with phacoemulsification, MSICS,
and large-incision ECCE, and they concluded that
for staff surgeons experienced with both phaco-
emulsification and MSICS, intraoperative compli-
cation rates were comparably low.
In the present study, the major intraoperative
complications in MSICS and phacoemulsification were
PCR (5 vs. 12.5%, respectively), failed CCC (7.5 vs. 10%,
respectively), and wound burn (0 vs. 12.5%, respectively);
these were statistically nonsignificant. Muhtaseb et al.
[13] assessed the risk factors for intraoperative
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Hard nuclear cataract phacoemulsification Enany 97

Table 5 Comparison of central corneal thickness between the two groups preoperatively and postoperatively at 1 and 8 weeks
Groups (n=80) Mean±SD P
Baseline 1 week 8 weeks Baseline to 1 week Baseline to 8 weeks 1–8 weeks
A (n=40) 573.04±23.95 576.48±21.16 568.60±22.30 0.028 0.068 0.085
B (n=40) 549.76±23.05 574.27±21.64 559.70±32.60

Table 6 Comparison of cell density preoperatively and postoperatively at 1 and 8 weeks

Groups (n=80) Mean±SD P
Baseline 1 week 8 weeks Baseline to 1 week Baseline to 8 weeks 1–8 weeks
A (n=40) 2313.92±342.82 2176.62±391.12 2248.90±343.80 0.890 0.0671 0.014
B (n=40) 23323.934±278.7 1992.21±28.39 2021.82±280.40

Table 7 Comparison of mean values of coefficient of variation between the two groups preoperatively and postoperatively at 1
and 8 weeks
Groups (n=80) Mean±SD P
Baseline 1 week 8 weeks Baseline to 1 week Baseline to 8 weeks 1–8 weeks
A (n=40) 39.62±6.84 41.29±7.55 42.46±8.09 0.063 0.051 0.941
B (n=40) 43.63±6.33 45.89±8.54 42.53±12.97

Table 8 Corrected distance visual acuity at the first day, first reported a conversion rate in phacoemulsification
week, eighth week, and uncorrected distance visual acuity at
eighth week postoperatively in both groups cases of 1.67%, whereas Dada et al. [2] reported a
Visual acuity N [n (%)]
conversion rate in phacoemulsification cases of 3.7%.
The reason for this higher rate of conversion to ECCE
PHACO MSICS
was the nature of this hard brown cataract, which makes
CDVA first day
the nucleus management more difficult and risky.
≥6/18 9 (22.5) 21 (52.5)
<6/18 31 (77.5) 19 (47.5)
χ2 6.27 In the present study, MSICS yielded better successful
P value 0.001 (significant) visual results than phacoemulsification (i.e. ≥6.18) in a
CDVA first week larger proportion of patients 1 day postoperatively
≥6/18 24 (60) 32 (80) (52.5 vs. 22.5%, respectively). The success rate
<6/18 16 (40) 8 (20) correlated with the absence of severe corneal edema
χ2 3.81 (5 vs. 25%, respectively). Venkatesh et al. [10] showed
P value 0.05 (significant)
that the MSICS group had less corneal edema than the
CDVA eighth week
≥6/18 34 (85) 37 (92.5)
phacoemulsification group on the first postoperative
<6/18 6 (15) 3 (7.5) day in cases with white cataract.
χ2 0.541
P value 0.36 (significant) Previous studies reported no significant difference in
UDVA eighth week endothelial cell loss among conventional ECCE,
≥6/18 30 (75) 34 (85) MSICS, and phacoemulsification groups [15].
<6/18 10 (25) 6 (15)
χ2 0.541 In the current study, the mean difference in central
P value 0.39 (significant)
corneal thickness at baseline, 1, and 8 weeks was
CDVA, corrected distance visual acuity; MSICS, manual small not statistically significant. In addition, the mean
incision cataract surgery; PHACO, phacoemulsification; UDVA,
uncorrected distance visual acuity. coefficient of variation and the mean±SD between
both groups were not statistically significant.
complications during phacoemulsification and found that
hard brown cataract is a well-known risk factor for PCR, El-Sayed et al. [8] reported both phacoemulsification
vitreous loss, failed CCC, zonular dialysis, lost nucleus, and MSICS achieved excellent visual outcomes with
and wound burn. low complication rates. MSICS is less dependent on
technology. Hence, it is less expensive and more
In the present study, conversion to ECCE was recorded appropriate for the treatment of advanced cataracts
in 20% of phacoemulsification cases. Ali et al. [14] prevalent in the developing countries.
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98 Delta Journal of Ophthalmology, Vol. 19 No. 2, April-June 2018
One of the limitations of this study was that only one
technique of phocoemulsification and one technique of
MSICS were compared. Other techniques may yield
different results. Another major limitation of the present
study was the short-term follow-up (8 weeks). However,
a prospective study from the USA evaluating the long-
term safety (5 years) of phacoemulsification found that
the rate of endothelial cell loss decreases over time [16].
Both MSICS and phacoemulsification yielded
excellent results, both anatomical and refractive.
However, MSICS appears to be more advantageous
than phacoemulsification in terms of speed, cost, and
independence from technology, and appears to more
suitable for dense cataracts and mass surgery [17].
Conclusion
Phacoemulsification and MSICS achieve comparable
and excellent visual outcomes in dealing with hard
brown cataract, with lower complication rates and
earlier postoperative visual rehabilitation in MSICS.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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