ORIGINAL ARTICLE

Year : 2015 | Volume : 22 | Issue : 3 | Page : 362369

Meta-analysis to compare the safety and efficacy of manual small incision cataract surgery and
phacoemulsification
Parikshit Gogate1, Jyoti Jaggernath B Optom2, Swapna Deshpande3, Kovin Naidoo2
1
African Vision Research Institute, Durban, South Africa; Dr. Gogate's Eye Clinic;
Department of Ophthalmology, Padmashri D. Y. Patil Medical College, Pimpri, Pune,
Maharashtra, India,
2
African Vision Research Institute, Durban, South Africa; Brien Holden Vision
Institute, Sydney, Australia,
3
Independent Biostatistician, Pune, Maharashtra, India

Abstract
Purpose: A systematic review and meta-analysis comparing the safety, efficacy, and expenses
related to phacoemulsification versus manual small incision cataract surgery (SICS).
Methods: PubMed, Cochrane, and Scopus databases were searched with key words manual
SICS 6/18 and 6/60; astigmatism and endothelial cell loss postoperatively, intra- and postoperative complications, phacoemulsification, and comparison of SICS and phacoemulsification.
Non-English language manuscripts and manuscripts not indexed in the three databases were also
search for comparison of SICS with phacoemulsification. Data were compared between
techniques for postoperative uncorrected and corrected distance visual acuity (UCVA and best
corrected visual acuity [BCVA], respectively) better than 6/9, surgical cost and duration of
surgery. The Oxford cataract treatment and evaluation team scores were used for grading
intraoperative and postoperative complications, uncorrected near vision.
Result: This review analyzed, 11 comparative studies documenting 76,838 eyes that had
undergone cataract surgery considered for analysis. UCVA of 6/18 UCVA and 6/18 BCVA were
comparable between techniques (P = 0.373 and P = 0.567, respectively). BCVA of 6/9 was
comparable between techniques (P = 0.685). UCVA of 6/60 and 6/60 BCVA aided and unaided
vision were comparable (P = 0.126 and P = 0.317, respectively). There was no statistical
difference in: Endothelial cell loss during surgery (P = 0.298), intraoperative (P = 0.964)
complications, and postoperative complications (P = 0.362). The phacoemulsification group had
statistically significantly less astigmatism (P = 0.005) and more eyes with UCVA of 6/9 (P =
0.040). UCVA at near was statistically significantly better with SICS due to astigmatism and
safer during the learning phase (P = 0.003). The average time for SICS was lower than
phacoemulsification and cost < of phacoemulsification.
Conclusion: The outcome of this meta-analysis indicated there is no difference between
phacoemulsification and SICS for BCVA and UCVA of 6/18 and 6/60. Endothelial cell loss and
intraoperative and postoperative complications were similar between procedures. SICS resulted
in statistically greater astigmatism and UCVA of 6/9 or worse, however, near UCVA was better.

Keywords: Astigmatism, Manual Small Incision Cataract Surgery, Meta-Analysis,

Phacoemulsification, Vision Outcome
How to cite this article:
Gogate P, Optom JB, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy
of manual small incision cataract surgery and phacoemulsification. Middle East Afr J
Ophthalmol 2015;22:362-9
How to cite this URL:
Gogate P, Optom JB, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy
of manual small incision cataract surgery and phacoemulsification. Middle East Afr J
Ophthalmol [serial online] 2015 [cited 2015 Aug 26];22:362-9. Available
from: http://www.meajo.org/text.asp?2015/22/3/362/159763
Introduction
Cataract remains the leading cause of avoidable blindness worldwide. [1] However, the safest,
most effective, and economical technique of cataract surgery remains debatable. [1],[2] Over the
past decade, manual small incision cataract surgery (SICS) has become an established surgical
alternative to phacoemulsification. Phacoemulsification is the preferred technique in the
developed world and tertiary centers of developing countries. [3],[4],[5],[6],[7],[8] Numerous randomized
controlled clinical trials (RCTs) have proved both techniques are safe and effective for
rehabilitating the vision of cataract patients. [9],[10],[11],[12],[13],[14] The advantage of both techniques
are sutureless, require small incisions, and result in faster visual rehabilitation.
Phacoemulsification requires a much smaller incision (3.2 mm) than SICS but the incision size
dependent on the type of phacoemulsification machine being used. An ultrasonic probe is used to
emulsify the cataractous crystalline lens, and the debris is aspirated with high vacuum. In manual
SICS, the entire crystalline lens is removed through a self-sealing scleral tunnel incision (5-7
mm) and a rigid polymethyl methacrylate intraocular lens implanted. A meta-analysis published
last year reported mostly comparable results with both techniques with phacoemulsification
providing better uncorrected visual acuity (UCVA) due to lower astigmatism. [15] The results were
drawn from the six RCTs, which were selected using the Jaded composite scale. [16] Although, the
study discussed postoperative UCVA and best-corrected visual acuity (BCVA), astigmatism and
complications, it did not comprehensively evaluate the complications (during and after surgery),
learning curves and surgeon time for SICS and phacoemulsification.
The significant backlog of individuals who are blind due to cataract awaiting surgery has resulted
in cataract being the leading cause of avoidable blindness globally, including in Africa. [1] The
reasons for this backlog include lack of access to eye care and lack of resources, specially trained
surgeons, to deliver cataract surgery safely, and reliably. We performed a meta-analysis
comparing SICS with phacoemulsification using a wider publication base, with an emphasis on
safety, learning curves, and resource inputs to get a more holistic view of the two techniques.
Comparisons were performed with the safety, reliability, effectiveness, and affordability of the

two surgical techniques.

Methods
This meta-analysis compared phacoemulsification and SICS. Ethics Board Approval was not
required because the study involved a review of published manuscripts, each of which had
Research Ethics Board Approval. PubMed, Cochrane, and Scopus databases were searched using
the keywords manual SICS and phacoemulsification. Non-English language manuscripts and
literature were not indexed that compared SICS to phacoemulsification were also reviewed.
Individual data from each study was grouped for the following objectives.

Uncorrected and BCVA at 6/18 cut-off (< 6/18 vs. 6/18)

Uncorrected and BCVA at 6/9 cut-off (< 6/9 vs. 6/9)

Uncorrected visual acuity 6/60 cut-off (< 6/60 vs. 6/60)

Astigmatism

Intraoperative complications

Postoperative complications

Endothelial cell loss

Duration of surgery

Cost of surgery

Postoperative UCVA at near.

The cut-off of 6/9 vision was selected because it is the standard acuity required for a driver's
license in most developed countries. World Health Organization (WHO) standards classify 6/18
and better vision as normal vision, and 6/60 is considered a severe visual impairment (economic
blindness). The legal norm for blindness in the United States and India is 6/60 (< 6/60 in the
better eye with available correction). We analyzed UCVA because many patients may not have
spectacles or cannot afford a pair of spectacles. Only astigmatism was considered because the
postoperative refractive spherical error was addressed by A-scan biometry and proper intraocular
lens implantation. The postoperative cylinder depended on the size, site, and type of incision,
which differed in the two techniques. The subjective refractive correction was considered for

astigmatism.
The Oxford Cataract Treatment and Evaluation Team (OCTET) grading was used to compare the
intraoperative and postoperative complications depending on their severity. [17] The frequency of
complications was graded for each technique. The severity of complications was graded, and
their effects on final visual acuity were compared. Endothelial cell loss, though not always
obvious during surgery, has the ability to affect corneal transparency in the long-term.
Endothelial cell loss was compared for both techniques. Intraoperative complications such as
posterior capsular rent, vitreous loss, zonular dialysis, and iridodialysis were compared between
groups. Postoperative complications were compared between techniques included
endophthalmitis, retinal detachment, posterior capsular opacification, postoperative corneal
edema that has the potential for corneal decompensation. The complication scores were
compared including and excluding high volume settings separately. The duration of each type of
surgery and the cost for surgery were compared. This was because surgeon time was a factor in
the cost of high volume Asian and African practices where surgeons are scarce. The learning
curves were compared between techniques as new surgeons would need to be trained for helping
eliminate the cataract backlog.
Statistical analyses were performed using STATA (version 10; StataCorp, College Station, Texas,
USA). Randomized control trials or parallel arms (one with phacoemulsification and one SICS)
design studies were included in the meta-analysis. Primary outcomes were presented either as
binary or continuous variables. Binary data (BCVA and UCVA related) were based on standard
cut-offs as explained previously. For binary variables, a pooled odds ratio (OR) with 95%
confidence interval (CI) were calculated. For the continuous outcomes, the standardized mean
difference (SMD) with 95% CI was calculated. Statistical heterogeneity was tested using the
Chi-square and I [2] statistic. To accommodate the diversity that each study is contributing, or
treatment effects that individual studies are estimating; the results using random effects modeling
are presented. A random-effects meta-analysis was performed using DerSimonian-Laird method.
[18]
Intraoperative and postoperative complication data were analyzed by taking weighted
estimates for analysis by assigning OCTET score to each of the complication as its weigh, where
data was not available (for certain visual acuity cut-offs or details such as endothelial cell loss or
astigmatism), those studies were excluded from the meta-analysis of that particular outcome
measure. Surgery time and cost data were obtained from a review manuscript. [19]
Results
The literature search resulted in 84 studies, which fulfilled the inclusion criteria. One study each
involved comparison of phacoemulsification and SICS with conventional extracapsular cataract
surgery. Totally, 38 articles were published in PubMed indexed journals, 30 in other indexed
journals, 2 in local journals while one was published in the proceedings of the All India
Ophthalmology Society's Annual Conference. [20] Eleven studies involved a direct comparison
between phacoemulsification and SICS. Of these, six were randomized control trials, [9],[10],[11],[12],
[13],[14]
and three others were direct comparison, one with near vision data, the second comparing
subluxated cataracts while the third compared immature cataract surgery with both techniques.
[20],[21],[22]
A study by Khanna et al. compared the safety and efficacy of both techniques during

their learning curves in a large residency and fellowship training program. [23] It had a large
sample size and variety of complications and dominated the forest plots comparing intraoperative
and postoperative complications. Hence, it was not included in the meta-analysis but discussed in
parallel, especially in view of safety and complications. A study by Haripriya et al. compared
SICS and phacoemulsification in a high volume setting. [24] With the exception of one study, [23]
the surgeons in all others studies were fully trained, experienced cataract surgeons. The total
sample size was 76,838 for the complications data from 11 studies. After excluding the Haripriya
et al. and Khanna et al. studies, the other 9 studies had a total sample size of 1768 cataract
surgeries.
Comparison of best corrected visual acuity at the 6/18 cut-off using phacoemulsification
versus the small incision cataract surgery technique
[Figure 1]a presents the comparison of BCVA < 6/18, relatively poor or borderline and poor
outcomes with phacoemulsification versus SICS.
Figure 1: (a) Comparison of best corrected visual acuity at 6/18 cutoff
using Phaco vs. SICS Meta Analysis based on data from 7 studies;
Event is BCVA < 6/18, OR: odds ratio, OR of Phaco over SICS. (b)
Comparison of Unaided corrected visual acuity at 6/18 cutoff using
Phaco vs. SICS Meta Analysis based on data from 5 studies; Event is
UCVA < 6/18, OR: odds ratio, OR of Phaco over SICS
Click here to view

Seven publications included BCVA data on 1229 eyes reported the proportion of patients with
BCVA < 6/18 versus BCVA of 6/18 or better postoperatively (around 6 weeks + 2 weeks).
Heterogeneity among study resulted was detected to be (I [2] = 0.0%). Analysis of these data
revealed that the difference in the proportion of participants with BCVA 6/18 postoperatively
between the phacoemulsification and SICS groups was not significant (OR: 0.73 95% CI: 0.341.82) (P = 0.989).
Comparison of uncorrected visual acuity at 6/18 cut-off
[Figure 1]b presents the comparison of UCVA < 6/18 versus UCVA >6/18, relatively poor or
borderline and poor outcomes with phacoemulsification versus SICS.
Five publications included UCVA data on 1082 eyes and reported the proportion of patients with
UCVA < 6/18 versus UCVA of 6/18 or better postoperatively (around 6 weeks + 2 weeks).
Heterogeneity among studies was estimated to be (I 2 = 53.10%). Analysis of the data revealed
that the difference in the proportion of participants with UCVA < 6/18 postoperatively between
techniques was not statistically significant (OR: 0.81; 95% CI: 0.51-1.29; I 2 = 53.1%, P = 0.373)
[Figure 1]b.
Comparison of 6/9 best corrected visual acuity

[Figure 2]a presents the comparison of BCVA >6/9 with phacoemulsification versus SICS. Three
publications reported the proportion of patients with BCVA >6/9 versus BCVA of < 6/9
postoperatively (6 weeks + 2 weeks). Random effect modeling was used and analysis of these
data indicated no statistical difference in the proportion of participants with postoperative UCVA
< 6/9 between techniques (OR: 0.81; 95% CI: 0.3-2.22; P = 0.685) [Figure 2]a.
Figure 2: (a) Comparison of best corrected visual acuity at 6/9 cutoff
using Phaco vs. SICS. (b) Comparison of unaided corrected visual
acuity at 6/9 cutoff using Phaco vs. SICS
Click here to view

Comparison of uncorrected visual acuity <6/9

[Figure 2]b compares UCVA < 6/9 between techniques. Three publications reported the
proportion of patients with UCVA >6/9 vs. UCVA < 6/9 postoperatively (6 weeks + 2 weeks).
Random effect modeling was used and data analysis indicated that there was a statistically
significant difference between the proportion of participants with postoperative UCVA >6/9 was
(OR: 0.71; 95% CI: 0.51-0.98; P = 0.04) [Figure 2]b.
Comparison of best corrected visual acuity and uncorrected visual acuity at 6/60 cut-off
[Figure 3]a compares BCVA < 6/60, a poor outcome with phacoemulsification versus SICS. Two
publications presented data on UCVA < 6/60 for 1777 eyes and reported the proportion of
patients with BCVA < 6/60 versus BCVA of 6/60 or better postoperatively (around 6 weeks + 2
weeks). Khanna et al. study were included in this analysis. The difference in BCVA < 6/60
postoperatively between techniques was not statistically significant (OR: 0.61; 95% CI: 0.331.19; P = 0.126) [Figure 3]a. [Figure 3]b compares aided visual acuity < 6/60, a poor outcome
with phacoemulsification versus SICS. There was no statistical difference between techniques
(OR: 2.19; 95% CI, 0.46-10.38; P = 0.314) [Figure 3]b.
Figure 3: (a) Comparison of best corrected visual acuity at 6/60 cutoff
using Phaco vs. SICS. (b) Comparison of unaided corrected visual
acuity at 6/60 cutoff using Phaco vs. SICS
Click here to view

Comparison of astigmatism with both techniques

[Figure 4] compares postoperative astigmatism after phacoemulsification versus SICS. Seven
studies evaluated 1303 eyes, comparing surgically induced astigmatism after
phacoemulsification and SICS. Phacoemulsification had statistically significantly lower than
SICS (SMD = 0.614; 95% CI: 1.05, 0.18; P = 0.005). The smaller incision size in
phacoemulsification led to significantly lower astigmatism than SICS.

Figure 4: Astigmatism using Phaco vs. SICS technique

Click here to view

Comparison of complications with both techniques

Khanna et al. compared outcomes while learning both techniques. Haripriya et al. presented data
from a high volume, high-quality cataract surgery practice. Hence, the intraoperative and
postoperative complications were analyzed separately, with and without these two manuscripts.
Comparison of intraoperative complications with each technique
[Figure 5] compares of intraoperative complications excluding Khanna et al. [3] study and
Haripriya et al. [24] study. Six studies that compared intraoperative complication for a total of
1220 eyes were reviewed. There was no difference in intraoperative complications between
techniques (P > 0.05).
Figure 5: (a) Intra-operative complications excluding studies with
learning curves and high volume surgery using Phaco vs. SICS
technique. (b) Intra-operative complications including high volume
setting. (c) Intra-operative complications including studies with
learning curves and high volume surgery using Phaco vs. SICS
technique
Click here to view

Comparison of postoperative complications with both techniques

[Figure 6] compares postoperative complications excluding Khanna et al. [23] study and Haripriya
et al. [24] study. Using the OCTET scores, there was no difference between the two techniques (P
= 0.362).
Figure 6: (a) Post-operative complications excluding studies with
learning curves and high volume surgery using Phaco vs. SICS
technique. (b) Post-operative complications including high volume
settings but excluding studies with learning curves. (c) Post-operative
complications including studies with learning curves and high volume
surgery
Click here to view

Comparison of endothelial cell loss with both techniques

[Figure 7] compares the change in endothelial cell count after each phacoemulsification and
SICS. Two studies compared endothelial cell loss after phacoemulsification and SICS each were
similarly weighted in the meta-analysis. The odds ratio was OR 1.00 (0.29, 2.90). One study [13]
reported higher loss with phacoemulsification and the other study reported no difference, even
though sodium hyaluronate and acrylic foldable lenses were used for phacoemulsification and
methylcellulose, and PMMA lenses were implanted for patients undergoing SICS in both studies.
Figure 7: Endothelial cell count loss using Phaco vs. SICS technique
Click here to view

Comparison of duration of surgery

The average duration of surgery of each technique is presented in [Table 1].
Table 1: Average duration of phacoemulsification and manual small
incision cataract surgery
Click here to view

A meta-analysis could not be performed as the published manuscripts did not report standard
deviations for each surgery. All except one of the five publications report much lower average
time for SICS than phacoemulsification. [19],[25]
Cost comparison
The cost of each technique is present in [Table 2]. The details are presented from a review article.
[19],[25],[26],[27],[28]

Table 2: Cost comparison between the techniques

Click here to view

Postoperative uncorrected near visual acuity

One prospective comparative study found the 35% of SICS patients had UCVA at near better
than N9 compared to 3% of phacoemulsification patients, when the A-scan and IOL power was
calculated for emmetropia at a distance. [20] Near UCVA between N 9 and < N 18 was reported in
46% of SICS patients and 16% of phacoemulsification patients. Near UCVA of N 18 or better
was reported in 81% of SICS patients and 19% of phaco patients. [20] Against-the-rule myopic
astigmatism helped more patients achieve better UCVA at near after SICS.

Discussion
The meta-analysis revealed no differences between phacoemulsification and SICS for BCVA and
UCVA at the 6/18 and 6/60 cut-offs and at the BCVA 6/9 cut-off. There was a small difference
favoring phacoemulsification for the 6/9 UCVA cut-off (P = 0.04). There were differences
between techniques in endothelial cell loss and intraoperative and postoperative complications
scores. However, SICS was safer for beginning surgeons (P = 0.03 for postoperative
complications).
The smaller incision size during phacoemulsification resulted in statistically lower postoperative
astigmatism. However, this did not translate into a clinically significant difference in UCVA.
6/18 is considered to be normal vision by WHO for most tasks and 6/9 is the international
driving license standard in many countries. Normal vision (6/18) postoperatively (UCVA and
BCVA) was reported in relatively equivalent numbers of SICS and phacoemulsification patients.
Similarly, almost equivalent numbers of patients undergoing each technique achieved the global
standard for driver's license vision (6/9). In terms of safety, vision < 6/60 was similar between
techniques. This finding was after considering manuscripts for white, hard cataracts, and
immature cataracts which were not a part of earlier meta-analysis, which was based solely on the
RCTs. Hence, despite lower postoperative astigmatism after phacoemulsification the UCVA of
these patients was not significantly better. Notably, the increased astigmatism in SICS in one
series from Miraj, India was responsible for better UCVA compared to phacoemulsification. [20]
Although the lack of postoperative astigmatism improved distance UCVA in phacoemulsification
patients, it was associated with impaired UCVA at near. [20] The unaided near vision was
important even in illiterate, rural communities for needlework, cooking and cleaning, answering
mobile phones and differentiating currency, and not just for reading and writing. Hence,
astigmatism is an issue in differentiating the two techniques; it does not seem to have much
impact on functional vision.
There are some limitations of this study including the drawbacks of the design of each individual
study included in this meta-analysis. In addition, most studies had a short follow-up (< 4
months). The longer follow-up would lead to a decrease in astigmatism but perhaps increased
posterior capsular opacification. However, to negate some of the drawbacks, we have considered
all the series comparing the two techniques, not just RTCs, to make the meta-analysis more wide
ranging.
Comparison of complications using OCTET scores indicated no difference in safety between
techniques. SICS was also safer during the learning phase for residents and trainees across two
large, reputed training programs in India. [23],[24] Some complications such as nucleus drop was
observed in phacoemulsification, while iridodialysis was reported in SICS. Descemet's
detachment, a not uncommon occurrence, was not discussed in any of the series that were
analyzed. The decrease in the endothelial cell count was comparable between techniques. There
was slightly greater decrease associated with phacoemulsification despite the use of high-density
viscoelastic devices. SICS had improved the visual outcomes in a large community eye care
center. [29]

Small incision cataract surgery was almost half the cost of phacoemulsification with easier
learning curves. The duration of surgery was also lower. Hence, a surgeon using SICS would
more productive if there was a backlog of cataract patients.
The current meta-analysis did indicate the similarity of results between phacoemulsification and
SICS even after considering white, black, hard, and subluxated cataracts. A similar study from
China evaluated only RTCs. Some randomized trials reported better UCVA in the
phacoemulsification arm of the study [9] however, this meta-analysis indicates that the difference
is not very significant. This outcome was similar to results from a recent Cochrane review. [30]
The comparable results in UCVA and BCVA; intraoperative and postoperative complications,
endothelial cell loss make SICS an equivalent technique to phacoemulsification. After
considering the saving in surgeon time, the easier and safer learning curves and the cost of the
procedure, SICS is the most suitable surgery for addressing the backlog of cataract blindness in
Africa. A study [31] from South Africa reported phacoemulsification was more effective. However,
the South African study [31] reported 7% eyes with postoperative visual acuity < 6/60 as compared
to the WHO standard of < 5%. [31] The South African study [31] also reported astigmatism ranged
up to 13 D and average astigmatism of one and half times greater than the published literature. In
addition, the surgeons are the South African study [31] used an 8 mm tunnel for SICS with suture
unlike the 5.5-6.5 mm in most series. In addition, 8% patients in the phacoemulsification arm
required conversion to SICS. [31]
The lesser duration of surgery and less need for equipment in SICS means the surgeon would be
more productive with a higher turnover in communities where there is large backlog of blindness
and trained human resources are scarce, as in many African countries. The more economical cost
would mean that the same budget could be used for a greater number of beneficiaries. In a
limited resource setting with large number of beneficiaries awaiting cataract surgery/backlog of
cataract blind, manual SICS is the technique of choice over phacoemulsification, as in Africa. In
any publicly funded programs, it would give the most cost effective results. Only when surgery is
self-paid would the small advantage of phacoemulsification for UCVA at a distance be justified.
Even in developed countries, SICS can be appropriate for dense cataracts where the posterior
capsule cannot be seen, phacodonesis is very hard cataracts (as a high phaco power setting is
needed) and for inexperienced surgeons. [32]
References
1.

Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol

2012;96:614-8.

2.

Chang DF. Tackling the greatest challenge in cataract surgery. Br J Ophthalmol

2005;89:1073-4.
[PUBMED]
Gogate PM, Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular cataract
surgery compared with manual small incision cataract surgery in community eye care
setting in western India: A randomised controlled trial. Br J Ophthalmol 2003;87:667-72.

3.

4.

Hennig A, Kumar J, Yorston D, Foster A. Sutureless cataract surgery with nucleus

extraction: Outcome of a prospective study in Nepal. Br J Ophthalmol 2003;87:266-70.

5.

Hennig A. Sutureless non-phaco cataract surgery: A solution to reduce worldwide cataract

blindness? Community Eye Health 2003;16:49-51.

6.

Astbury N. Converting from ECCE to SICS. Community Eye Health 2009;22:6-7.

7.

Gogate PM. Small incision cataract surgery: Complications and mini-review. Indian J
Ophthalmol 2009;57:45-9.
[PUBMED]
Gogate P. Clinical trials of manual small incision cataract surgery and standard
extracapsular cataract surgery: Results of quality of life. J Community Eye Health
2003;16:54-5.

8.

9.

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;112:86974.

10. Gogate P, Ambardekar P, Kulkarni S, Deshpande R, Joshi S, Deshpande M. Comparison of

endothelial cell loss after cataract surgery: Phacoemulsification versus manual smallincision cataract surgery: Six-week results of a randomized control trial. J Cataract Refract
Surg 2010;36:247-53.
11. 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.
12. Venkatesh R, Tan CS, Sengupta S, Ravindran RD, Krishnan KT, Chang DF.
Phacoemulsification versus manual small-incision cataract surgery for white cataract. J
Cataract Refract Surg 2010;36:1849-54.
13. George R, Rupauliha P, Sripriya AV, Rajesh PS, Vahan PV, Praveen S. Comparison of
endothelial cell loss and surgically induced astigmatism following conventional
extracapsular cataract surgery, manual small-incision surgery and phacoemulsification.
Ophthalmic Epidemiol 2005;12:293-7.
14. Ghosh S, Roy I, Biswas PN, Maji D, Mondal LK, Mukhopadhyaya S, et al. Prospective
randomised comparative study of macular thickness following phacoemulsification and
manual small incision cataract surgery. Acta Ophthalmol 2010;88:102-6.
15. Zhang JY, Feng YF, Cai JQ. Phacoemulsification versus manual small-incision cataract
surgery for age-related cataract: Meta-analysis of randomized controlled trials. Clin
Experiment Ophthalmol 2013;41:379-86.

16. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing
the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin
Trials 1996;17:1-12.
17. Use of a grading system in the evaluation of complications in a randomised controlled trial
on cataract surgery. Oxford Cataract Treatment and Evaluation Team (OCTET). Br J
Ophthalmol 1986;70:411-4.
[PUBMED]
18. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication
bias. Biometrics 1994;50:1088-101.
19. Jaggernath J, Gogate P, Moodley V, Naidoo N. A comparison of cataract surgery techniques
in the developing world: Safety, efficacy, cost effectiveness and public health. Eur J
Ophthalmol 2014;24:520-6.
20. Kulkarni AN, Bhomaj P, Badhe G. Manual Small Incision Cataract Surgery is Almost as
Effective but Less Expensive than Phacoemulsification. Proceedings of the 73 rd Annual
Conference of the All India Ophthalmology Society 2010 at Kolkata, Cataract Session IV;
2010. p. 146-8.
21. Goel R, Kamal S, Kumar S, Kishore J, Malik KP, Angmo Bodh S, et al. Feasibility and
Complications between phacoemulsification and manual small incision surgery in
Subluxated cataract. J Ophthalmol 2012;2012:205139.
22. Singh SK, Winter I, Surin L. Phacoemulsification versus small incision cataract surgery
(SICS): Which one is a better surgical option for immature cataract in developing countries?
Nepal J Ophthalmol 2009;1:95-100.
23. Khanna R, Kaza S, Palmanar Subash Shanta G, Sangwan V. Comparision of manual small
incision cataract surgery and phacoemulsification performed by ophthalmology trainees in a
tertiary eye care hospital in India: A retrospective cohort design. BMJ Open
2012;2:e001035.
24. Haripriya A, Chang DF, Reena M, Shekhar M. Complication rates of phacoemulsification
and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg
2012;38:1360-9.
25. Gogate P, Deshpande M, Nirmalan PK. Why do phacoemulsification? Manual smallincision cataract surgery is almost as effective, but less expensive. Ophthalmology
2007;114:965-8.
26. Venkatesh R, Chang D, Muralikrishnan R, Hemal K, Gogate P, Sengupta S. Manual small
incision cataract surgery: A review. Asia Pac J Ophthalmol 2012;1:113-9.
27. 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;87:843-6.
28. Muralikrishnan R, Venkatesh R, Prajna NV, Frick KD. Economic cost of cataract surgery
procedures in an established eye care centre in Southern India. Ophthalmic Epidemiol
2004;11:369-80.
29. Gogate P, Khandekar R, Vakil V, Limburg H, Deshpande M. Monitoring and modernization
improves the outcome of cataract surgery in Maharashtra, India. J Cataract Refract Surg
2011;37:328-34.
30. Riaz Y, de Silva SR, Evans JR. Manual small incision cataract surgery (MSICS) with
posterior chamber intraocular lens versus phacoemulsification with posterior chamber
intraocular lens for age-related cataract. Cochrane Database Syst Rev
2013;10:CD008813.
31. Cook C, Carrara H, Myer L. Phaco-emulsification versus manual small-incision cataract
surgery in South Africa. S Afr Med J 2012;102:537-40.
32. Gogate P, Thomas R. Role of manual small incision cataract surgery in Australia and
developed nations. Clin Experiment Ophthalmol 2014;42:709-10.