Cataract, a progressive opacification of the crystalline lens, remains the leading cause of preventable blindness worldwide. According to the World Health Organization (WHO), cataract accounts for nearly 51% of global blindness, affecting more than 20 million people, particularly in low- and middle-income countries where access to surgical care is limited. The burden of cataract-related visual impairment is significant in India, where cataract contributes to approximately 60–70% of avoidable blindness cases. With increasing life expectancy and improved awareness, the demand for high-quality cataract surgery with optimal postoperative visual outcomes has increased exponentially in recent decades.[1] Cataract surgery has undergone a remarkable transformation over the last century-from large-incision intracapsular and extracapsular cataract extraction techniques to modern small-incision and phacoemulsification procedures. The advent of Manual Small Incision Cataract Surgery (MSICS) and Phacoemulsification represents two dominant surgical paradigms currently practiced in both resource-limited and resource-adequate settings. Each technique aims to restore transparency of the optical media and optimize visual acuity with minimal complications and rapid recovery, yet they differ in their surgical approach, equipment requirements, learning curve, and cost implications.[2] Phacoemulsification, introduced by Charles Kelman in the late 1960s, revolutionized cataract surgery through the use of ultrasonic energy to emulsify the nucleus, followed by aspiration through a small incision of approximately 2.2–3.2 mm. The technique minimizes surgically induced astigmatism, allows early wound healing, and offers rapid visual rehabilitation. However, it is technologically demanding, cost-intensive, and requires advanced instrumentation and continuous irrigation–aspiration systems. Its effectiveness is well-established in high-income countries, but in developing nations, its widespread adoption is constrained by infrastructural and economic limitations.[3] On the other hand, Manual Small Incision Cataract Surgery (MSICS) evolved as an effective and economical alternative, particularly suited to high-volume settings in developing countries. It involves manual delivery of the nucleus through a self-sealing scleral tunnel incision of approximately 6–7 mm, eliminating the need for expensive phacoemulsification equipment while maintaining comparable visual outcomes. The technique is faster, cost-effective, and less technology-dependent, making it the preferred choice for community outreach and national blindness control programs. Nevertheless, concerns persist regarding slightly increased postoperative astigmatism and longer wound-healing time compared to phacoemulsification.[4] Aim To compare the visual acuity outcomes in cataract surgery performed by Phacoemulsification and Manual Small Incision Cataract Surgery (MSICS). Objectives 1. To assess and compare postoperative uncorrected and best-corrected visual acuity between phacoemulsification and MSICS techniques. 2. To evaluate intraoperative and postoperative complications associated with both techniques. 3. To analyze postoperative recovery, including wound healing and surgically induced astigmatism, between the two surgical modalities.

Source of Data The present study utilized data collected from patients attending the Ophthalmology Department at a tertiary care teaching hospital. All patients diagnosed with age-related cataract and meeting inclusion criteria were enrolled after obtaining informed written consent. Study Design This was a comparative, prospective, observational study comparing visual outcomes following Phacoemulsification and Manual Small Incision Cataract Surgery (MSICS). Study Location The study was conducted at the Department of Ophthalmology, at tertiary care teaching hospital. Study Duration The study was conducted over a period of 18 months, from January 2023 to June 2024, including patient recruitment, surgery, follow-up, and data analysis. Sample Size A total of 250 patients were included-125 patients underwent phacoemulsification and 125 patients underwent MSICS. Sample size was determined based on previous literature showing a mean difference of 0.1 LogMAR in postoperative visual acuity between groups, with 80% power and 5% level of significance. Inclusion Criteria 1. Patients aged ≥40 years diagnosed with age-related cataract. 2. Patients fit for cataract surgery under local or topical anesthesia. 3. Willingness to undergo either Phacoemulsification or MSICS. 4. Patients who provided informed consent and agreed to follow-up visits. Exclusion Criteria 1. Presence of pre-existing ocular comorbidities affecting vision (e.g., glaucoma, macular degeneration, diabetic retinopathy). 2. Traumatic or complicated cataracts. 3. History of previous intraocular surgery. 4. Corneal opacity or irregular astigmatism precluding accurate refraction. 5. Patients lost to follow-up or with incomplete postoperative data. Procedure and Methodology All enrolled patients underwent a thorough preoperative ophthalmic evaluation, including visual acuity assessment (Snellen chart), slit-lamp biomicroscopy, intraocular pressure measurement (Goldmann tonometry), fundus examination, and biometry (using A-scan ultrasound and keratometry) for intraocular lens power calculation using SRK/T formula. Patients were randomly allocated into two groups: • Group A: Phacoemulsification • Group B: Manual Small Incision Cataract Surgery (MSICS) Both surgeries were performed under peribulbar anesthesia by experienced ophthalmic surgeons using standard aseptic precautions. Phacoemulsification Technique: A 2.8 mm clear corneal incision was made. Capsulorrhexis was performed followed by hydrodissection and phacoemulsification of the nucleus using the divide-and-conquer technique. A foldable posterior chamber intraocular lens (IOL) was implanted in the capsular bag. MSICS Technique: A self-sealing scleral tunnel incision (6.5–7 mm) was made 2 mm posterior to the limbus. After capsulorrhexis and hydrodissection, the nucleus was prolapsed into the anterior chamber and delivered manually using viscoexpression. A rigid PMMA IOL was placed in the capsular bag. The incision was self-sealing, and sutures were avoided unless indicated. Postoperatively, all patients received standard topical antibiotic–steroid combination therapy. Visual acuity and anterior segment evaluation were performed on postoperative days 1, 7, and 30. The key outcomes assessed included Uncorrected Visual Acuity (UCVA), Best-Corrected Visual Acuity (BCVA), surgically induced astigmatism, and complication rates. Sample Processing All visual acuity measurements were converted to LogMAR units for statistical analysis. Data were recorded in structured case sheets and cross-verified for accuracy. Preoperative and postoperative data were tabulated for both groups for comparison. Statistical Methods Data were analyzed using SPSS version 25.0. Descriptive statistics were presented as mean ± standard deviation for continuous variables and percentages for categorical data. Between-group comparisons were performed using the Student’s t-test for continuous variables and the Chi-square test for categorical variables. A p-value <0.05 was considered statistically significant. Effect size (Cohen’s d or Risk Difference) and 95% confidence intervals were calculated for key outcomes. Data Collection Data were collected prospectively using a structured proforma that included demographic details, preoperative findings, operative details, and postoperative outcomes. Follow-up assessments were conducted at day 1, week 1, and month 1 post-surgery. The final visual outcome was recorded at 4 weeks.

Table 1: Primary visual acuity outcomes at 1 month (N = 250) Outcome Phaco (n=125) n(%) or Mean ± SD MSICS (n=125) n(%) or Mean ± SD Test of significance Effect size (95% CI) p-value UCVA (LogMAR) 0.18 ± 0.12 0.26 ± 0.15 Welch t(≈236.6)=-4.66 Mean diff = -0.08 (-0.114 to -0.046) <0.001 BCVA (LogMAR) 0.06 ± 0.08 0.08 ± 0.09 Welch t(≈244.6)=-1.86 Mean diff = -0.02 (-0.041 to +0.001) 0.064 UCVA ≥6/18 112 (89.6%) 102 (81.6%) χ²(1)=3.29 RD = +8.0% (-0.6% to +16.6%) 0.070 BCVA ≥6/9 109 (87.2%) 104 (83.2%) χ²(1)=0.80 RD = +4.0% (-4.8% to +12.8%) 0.372 Notes: Lower LogMAR = better visual acuity. RD = Risk Difference (Phaco - MSICS). At one month postoperatively, patients who underwent phacoemulsification demonstrated superior visual acuity outcomes compared to those who underwent Manual Small Incision Cataract Surgery (MSICS). The mean uncorrected visual acuity (UCVA) in the phacoemulsification group was 0.18 ± 0.12 LogMAR, significantly better than 0.26 ± 0.15 LogMAR in the MSICS group (t ≈ -4.66, p < 0.001). The mean difference of -0.08 LogMAR (95% CI: -0.114 to -0.046) indicates a clinically relevant advantage favoring phacoemulsification. Similarly, the best-corrected visual acuity (BCVA) was slightly better in the phaco group (0.06 ± 0.08 LogMAR) compared to MSICS (0.08 ± 0.09 LogMAR), though this difference narrowly missed statistical significance (p = 0.064). When visual outcomes were expressed in Snellen equivalents, 89.6% of patients in the phaco group achieved UCVA ≥6/18 compared to 81.6% in the MSICS group (χ² = 3.29, p = 0.070), while 87.2% versus 83.2%, respectively, achieved BCVA ≥6/9 (χ² = 0.80, p = 0.372). Although these categorical differences were not statistically significant, the overall trend favored phacoemulsification. Table 2: Postoperative UCVA and BCVA by follow-up time point (N = 250) Time point & Metric Phaco (n=125) Mean ± SD MSICS (n=125) Mean ± SD Test of significance Effect size (95% CI) p-value Day 1 – UCVA (LogMAR) 0.42 ± 0.20 0.58 ± 0.22 Welch t(≈245.8)=-6.02 Mean diff = -0.16 (-0.212 to -0.108) <0.001 Week 1 – UCVA (LogMAR) 0.22 ± 0.13 0.30 ± 0.16 Welch t(≈238.0)=-4.34 Mean diff = -0.08 (-0.116 to -0.044) <0.001 Month 1 – UCVA (LogMAR) 0.18 ± 0.12 0.26 ± 0.15 Welch t(≈236.6)=-4.66 Mean diff = -0.08 (-0.114 to -0.046) <0.001 Day 1 – BCVA (LogMAR) 0.30 ± 0.18 0.41 ± 0.20 Welch t(≈245.3)=-4.57 Mean diff = -0.11 (-0.157 to -0.063) <0.001 Week 1 – BCVA (LogMAR) 0.12 ± 0.10 0.16 ± 0.11 Welch t(≈245.8)=-3.01 Mean diff = -0.04 (-0.066 to -0.014) 0.003 Month 1 – BCVA (LogMAR) 0.06 ± 0.08 0.08 ± 0.09 Welch t(≈244.6)=-1.86 Mean diff = -0.02 (-0.041 to +0.001) 0.064 Interpretation: Phaco shows faster early recovery (Day 1, Week 1) in both UCVA and BCVA; by Month 1, UCVA advantage persists, BCVA difference narrows to borderline non-significance. The postoperative visual trajectory clearly demonstrated that patients undergoing phacoemulsification recovered visual acuity more rapidly during the early postoperative period compared to those undergoing MSICS. On postoperative day 1, the mean UCVA was 0.42 ± 0.20 LogMAR in the phaco group versus 0.58 ± 0.22 LogMAR in the MSICS group, with a highly significant difference (p < 0.001). A similar trend was seen at one week (0.22 ± 0.13 vs. 0.30 ± 0.16 LogMAR, p < 0.001), and this difference persisted at one month (0.18 ± 0.12 vs. 0.26 ± 0.15 LogMAR, p < 0.001). In terms of BCVA, phacoemulsification also demonstrated superior early results. On day 1, BCVA was significantly better in the phaco group (0.30 ± 0.18 vs. 0.41 ± 0.20 LogMAR, p < 0.001), and at one week, the difference remained statistically significant (0.12 ± 0.10 vs. 0.16 ± 0.11 LogMAR, p = 0.003). By one month, however, the BCVA values between the two groups converged (0.06 ± 0.08 vs. 0.08 ± 0.09 LogMAR, p = 0.064), suggesting that while phacoemulsification offers faster early visual rehabilitation, the final best-corrected visual potential at one month is comparable between the two techniques. Overall, the data indicate that phacoemulsification leads to quicker visual recovery and better early uncorrected vision, which may have a significant impact on postoperative patient satisfaction and functional independence in the immediate recovery period. Table 3: Intraoperative and postoperative complications (N = 250) Complication Phaco (n=125) n(%) MSICS (n=125) n(%) Test of significance Effect size (95% CI) p-value Posterior capsular rupture 4 (3.2%) 6 (4.8%) χ²(1)=0.42 RD = -1.6% (-6.5% to +3.3%) 0.518 Zonular dialysis 2 (1.6%) 5 (4.0%) χ²(1)=1.33 RD = -2.4% (-6.5% to +1.7%) 0.249 Iris prolapse 1 (0.8%) 4 (3.2%) χ²(1)=1.85 RD = -2.4% (-5.9% to +1.1%) 0.174 Descemet detachment 3 (2.4%) 2 (1.6%) χ²(1)=0.20 RD = +0.8% (-2.7% to +4.3%) 0.651 Wound burn 1 (0.8%) 0 (0.0%) χ²(1)=1.01 RD = +0.8% (-0.8% to +2.4%) 0.315 Corneal edema Day 1 (≥grade 1) 18 (14.4%) 28 (22.4%) χ²(1)=2.69 RD = -8.0% (-17.6% to +1.6%) 0.101 AC reaction ≥2+ Day 1 12 (9.6%) 19 (15.2%) χ²(1)=1.82 RD = -6.0% (-13.7% to +2.5%) 0.177 IOP spike Day 1 (>25 mmHg) 9 (7.2%) 13 (10.4%) χ²(1)=0.80 RD = -3.2% (-10.2% to +3.8%) 0.371 Cystoid macular edema (6 weeks) 3 (2.4%) 5 (4.0%) χ²(1)=0.52 RD = -1.6% (-6.0% to +2.8%) 0.472 Endophthalmitis 0 (0.0%) 1 (0.8%) χ²(1)=1.01 RD = -0.8% (-2.4% to +0.8%) 0.315 Notes: RD = Phaco - MSICS. None of the between-group differences in adverse events reached statistical significance; absolute event rates remained low across both arms. The overall rate of intraoperative and postoperative complications was low in both groups, reflecting the safety of both surgical techniques when performed by experienced surgeons. Posterior capsular rupture occurred in 3.2% of phacoemulsification cases and 4.8% of MSICS cases (p = 0.518), and zonular dialysis was seen in 1.6% and 4.0%, respectively (p = 0.249). Iris prolapse occurred slightly more frequently in MSICS (3.2%) than in phacoemulsification (0.8%), though this was not statistically significant (p = 0.174). Minor postoperative complications, such as corneal edema on day 1, were more common in the MSICS group (22.4%) compared to phaco (14.4%), again without statistical significance (p = 0.101). Anterior chamber (AC) inflammation ≥2+ was seen in 15.2% of MSICS cases versus 9.6% of phaco cases (p = 0.177). Similarly, transient IOP spikes >25 mmHg were slightly more frequent in the MSICS group (10.4%) than in the phaco group (7.2%) (p = 0.371). Rare events such as cystoid macular edema (CME) and endophthalmitis were observed at low rates (≤4%) across both groups, with no statistically significant differences. Importantly, there were no cases of severe vision-threatening complications or permanent loss of visual function in either technique. Table 4: Postoperative recovery & surgically induced astigmatism (SIA) (N = 250) Recovery metric Phaco (n=125) MSICS (n=125) Test of significance Effect size (95% CI) p-value SIA at 1 month (D) 0.61 ± 0.31 0.94 ± 0.45 Welch t(≈220.1)=-6.75 Mean diff = -0.33 D (-0.426 to -0.234) <0.001 Time to resume routine activities (days) 4.3 ± 1.8 6.1 ± 2.1 Welch t(≈242.3)=-7.28 Mean diff = -1.80 days (-2.285 to -1.315) <0.001 Endothelial cell loss at 1 month (%) 8.4 ± 3.2 10.2 ± 3.8 Welch t(≈241.0)=-4.05 Mean diff = -1.80% (-2.671% to -0.929%) <0.001 Wound stability by Week 1 (Seidel-, no edema ≥1) 118 (94.4%) 107 (85.6%) χ²(1)=5.50 RD = +8.8% (+1.4% to +16.2%) 0.019 Suture required 0 (0.0%) 7 (5.6%) χ²(1)=7.42 RD = -5.6% (-9.6% to -1.6%) 0.006 Table 4 demonstrates that patients who underwent phacoemulsification experienced a faster and smoother postoperative recovery compared to those who underwent MSICS. The mean surgically induced astigmatism (SIA) at one month was significantly lower in the phaco group (0.61 ± 0.31 D) than in the MSICS group (0.94 ± 0.45 D, p < 0.001), reflecting the advantage of smaller incisions in maintaining corneal curvature. The time to resume routine activities was also shorter for phacoemulsification (4.3 ± 1.8 days) versus MSICS (6.1 ± 2.1 days, p < 0.001), indicating quicker visual rehabilitation. Additionally, endothelial cell loss at one month was significantly less in the phaco group (8.4 ± 3.2%) compared to MSICS (10.2 ± 3.8%, p < 0.001), suggesting lesser intraocular trauma with phacoemulsification. Wound stability by week one was higher in the phaco group (94.4%) than in MSICS (85.6%, p = 0.019), while suture requirement was nil in phacoemulsification but needed in 5.6% of MSICS cases (p = 0.006).

Table 1 reinforce this: UCVA ≥ 6/18 favored phaco (89.6% vs 81.6%; p = 0.070) and BCVA ≥ 6/9 was high in both groups (87.2% vs 83.2%; p = 0.372). Such equivalence in final BCVA with UCVA edge for phaco aligns with the RCT by Nitikarun P et al.(2025)[5] (six-week outcomes) and with systematic syntheses indicating short-term UCVA superiority for phaco but similar best-corrected outcomes thereafter. Pathak M et al.(2022)[6] When viewed longitudinally (Table 2), our time-course-large Day 1 gap that narrows by Week 1 and narrows further for BCVA by Month 1-matches the trajectory described in meta-analytic work and multicenter evaluations where phaco’s smaller incision drives quicker optical quality early, but refraction and capsular stability allow MSICS to catch up in BCVA by 4–6 weeks. Ahmed MS.(2021)[7] & Singh R et al.(2022)[8] Complication profiles (Table 3) were low and statistically similar across groups (PCR 3.2% vs 4.8%; CME 2.4% vs 4.0%; endophthalmitis rare), consistent with RCTs and meta-analyses demonstrating no major safety penalty with either technique in experienced hands. Slightly higher early corneal edema and AC reaction with MSICS in our series (non-significant) is a commonly reported signal, likely reflecting wound size and nucleus delivery mechanics rather than fundamental safety differences. Ahmed I et al.(2023)[9] Our recovery metrics (Table 4; not reproduced here) underpin the UCVA edge: lower SIA with phaco has been repeatedly documented and explains better uncorrected vision at equivalent time points; several comparative series-across routine senile cataracts and even hard nuclei-report the same directionality (less SIA and quicker functional return with phaco, but broadly comparable final BCVA) Bhutto IA et al.(2021)[10] & Okoye GS et al.(2025)[11].

The present comparative study of 250 patients undergoing cataract surgery by Phacoemulsification and Manual Small Incision Cataract Surgery (MSICS) demonstrates that both techniques are highly effective and safe in restoring visual acuity. Phacoemulsification provided significantly better uncorrected visual acuity (UCVA) at all postoperative intervals and faster visual recovery, while best-corrected visual acuity (BCVA) at one month was comparable between the two groups, indicating similar final visual potential. Complication rates were low and not significantly different between the groups, emphasizing that both methods are reliable when performed by skilled surgeons. These findings reinforce the suitability of phacoemulsification for centers prioritizing rapid rehabilitation and minimal astigmatism, whereas MSICS remains an excellent, cost-effective alternative for high-volume settings, especially in developing regions. Thus, the choice of surgical technique should be individualized based on patient needs, cataract morphology, surgeon expertise, and resource availability.

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