Cataract surgery is the most common surgical procedure performed in

routine ophthalmic practice. It has undergone tremendous evolution,

and the incision size has progressively reduced from 10–12 mm in
extracapsular cataract surgery (ECCE) to 6–8 mm for manual small-
incision cataract surgery (MSICS) and 2.2–2.8 mm in
phacoemulsification. With a massive backlog of cataract, everyone
cannot afford private surgery like phacoemulsification in the periphery.
Moreover, annual maintenance of the machine, cost of foldable IOLs,
need for greater skill, learning curve, and difficulty in performing the
surgery in mature and brown cataracts are other barriers.

Phacoemulsification is the accepted standard in the developed world.

Recent advances such as Femtosecond laser technology and 3D
surgeries are on the rise. However, the limitations of
phacoemulsification such as the higher cost, longer learning curve, and
higher complication rates make MSICS a better option for the cities
outside Dhaka.
MSICS is a technique with an easier learning curve and costing
comparatively less with equal visual outcomes. This has raised the need
for constant modifications and improvements in an attempt to achieve
MSICS results equivalent to phacoemulsification.

Case selection is very important for an average surgeon doing

phacoemulsification, and duration of surgery and incidence of
intraoperative complications varies with the nucleus density. Certain
cataracts, like hypermature, Morgagnian or traumatic cataracts are
difficult to handle with phacoemulsification. Manual SICS can be
performed in almost all types of cataracts.

Phacoemulsification becomes more challenging due to the density of

the cataract, loss of the capsulorhexis, zonular dialysis (ZD),
iridodialysis, corneal haze, or any other reason necessitating
discontinuation of phacoemulsification. There are times when
continuing with phacoemulsification is no longer prudent. One of the
commonest and feared complications is posterior capsule rupture
(PCR). When a PCR occurs early in the surgery, with most of the
nucleus still present, it is safer to stop phacoemulsification and convert
to a large-incision cataract surgery such as manual small-incision
cataract surgery (MSICS). The MSICS wound is self-sealing and has valve
architecture that closes automatically during surgery, is more secure,
does not open up with minor injuries, and produces a postoperative
astigmatism that is more predictable. Vitrectomy is easier to perform in
MSICS as the chamber is closed and remains deep. After a PCIOL is
securely placed, one can expect similar results as a phacoemulsification
surgery.
The main incision plays a vital role in

Approximately 1.5 mm behind the limbus, a partial scleral incision is

placed at approximately one-third of the scleral thickness.[21] The
incision is placed behind the blue–white junction and varies from 5.5 to
8 mm in length. The length of the incision is governed by the density
and hardness of the nucleus.[4] The incision configuration can be
straight, chevron or V-shaped incision, frown incision, Blumenthal side
cut, and smile-shaped incision.
Astigmatism management in MSICS requires a clear understanding of
the axis of astigmatism and a conceptual approach for planning the
scleral tunnel incision. Smile incisions are easier to construct but result
in increased astigmatism. Straight incisions result in moderately
induced astigmatism. A frown incision is challenging to construct but
causes minimal astigmatism. MSICS can be considered a refractive
procedure in expert hands to minimize astigmatism permanently. This
will reduce the preoperative refractive error maintaining sphericity.
ADVANTAGES OF MANUAL SMALL INCISION CATARACT SURGERY
INCLUDE:
Unlike phacoemulsification, MSICS is a low-cost surgical
procedure that does not require expensive equipment. The cost of a
foldable IOL is much higher
It is a high-volume surgery learned in a short span of time.
It is suitable for all types of cataracts.
MSICS rehabilitation is quicker with shorter healing times due to the
lack of suture-related issues.
There is less postoperative follow-up with MSICS.
The learning curve for MSICS is shorter than that for
phacoemulsification.